THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


TRANSACTIONS 

OF  THE 

AMERICAN  CONGRESS 


ON 


INTERNAL   MEDICINE 


SECOND  SCIENTIFIC  SESSION,  PITTSBURGH,  PA. 
DECEMBER  27-28.  1917 


Edited  by 
JOSEPH  H.   BYRNE 

Assisted  by 
EDWARD  E.  CORNWALL 


Published  for  the  Congress  by  the  Burr  Printing  House,  New  York 
Nineteen  Hundred  and  Eighteen 


Biomedical 
Library 

AM43fe 
1117 


OFFICERS,  1917-1918 


Glentworth  R.  Butler,  President,  Brooklyn,  N.  Y. 

Elias  H.  Bartley,  Vice-President,  Brooklyn,  N.  Y. 

*Heinrich  Stern,  Secretary-General,  New  York,  N.  Y. 

Joseph  11.  Byrne,  Assistant  Secretary-General,  New  York,  N.  Y. 

Augustus  Caille,  Treasurer,  New  York,  N.  Y. 


COUNCILORS,  1917-1918 

Charles  D.  Aaron,  Detroit,  Mich.,  1921. 
James   M.  Anders,   Philadelphia,   Pa.,    1919. 
Noble  P.  Barnes,  Washington,  D.  C,  1921. 
Henry  Wald  Bettmann,  Cincinnati,  Ohio,  1918. 
Louis  Faugeres  Bishop,  New  York,  N.  Y.,  1920 
Harlow  Brooks,  New  York,  N.  Y.,  1919. 
Joseph  H.  Byrne,  New  York,  N.  Y.,  1920. 
Edward  E.  Cornwall,  Brooklyn,  N.  Y.,  1920. 
Judson  Daland,  Philadelphia,  Pa.,  1921. 
Britton  D.  Evans,  Morristown,  N.  J.,  1921. 
Henry  A.  Fairbairn,  Brooklyn,  N.  Y.,  1918. 
Charles  Lyman  Greene,  St.  Paul,  Minn.,  1918. 
John  C.  Hemmeter,  Baltimore,  Md.,  1919. 
Clement  R.  Jones,  Pittsburgh,  Pa.,  1918. 
John  A.  Lichty,  Pittsburgh,  Pa.,  1919. 
William  H.  Mercur,  Pittsburgh,  Pa.,  1922. 
Francis  M.  Pottenger  Monrovia,  Cal.,  1921. 
Thomas  M.  Reilly,  New  York,  N.  Y.,  1920. 
Charles  E.  de  M.  Sajous,  Philadelphia,  Pa.,  1922. 
Thomas  E.  Satterthwaite,  New  York,  N.  Y.,  1922. 
William  H.  Stewart,  New  York,  N.  Y.,  1920. 
Frederick  Tice,  Chicago,  111.,  1918. 
Henry  Enos  Tuley,  Louisville,  Ky.,  1922. 
Joshua  M.  Van  Cott,  Brooklyn,  N.  Y.,  1919. 
Reynold  Webb  Wilcox,  New  York,  N.  Y.,  1922. 
*Deceased. 


635218 


CONTEXTS 

PAGE 

Officers,  1917-1918 3 

Councillors,  1917-1918 3 

Address  of  Welcome,  by  John  A.  Lichty 7 

Response  to  Address  of  Welcome,  by  Thomas  F.  Reilly 8 

Address  of  the  Vice-President,  by  E.  H.  Bartley 9 

Address  of  the  Secretary-General,  by  Heinrich  Stern 14 

Report  of  the  Treasurer,  by  Augustus  Caille 15 

Report  of  Deaths  of  Members,  by  E.  E.  Cornwall 16 

Election  of  Officers 16 

Roentgenology  and  the  Internist,  by  C.  D.  Aaron 17 

Roentgen  Diagnosis  of  Diseases  of  the  Chest,  by  G.  C.  John- 
ston      22 

A  Resume  of  Roentgen  Findings  in  Abdominal  Pathology,  by 

W.  A.  Evans 33 

The  Value  and  Limitations  of  Radiotherapy  in  Internal  Medi- 
cine, by  R.  H.  Boggs 45 

Communicable  Diseases  Among  Soldiers,  by  W.  H.  Parks'.  ...  56 

Some  Problems  of  Cardiovascular  Disease,  by  E.  E.  Cornwall.  .  65 

The  Role  of  Infection  in  the  Production  of  "So-called  Perni- 
cious" Anemia,  by  Frank  Smithies 71 

Discussion  of  Papers  of  Drs.  Cornwall  and  Smithies,  by  Drs. 
Wilcox,    Field,    Tice.    Barr,    Barach,    Caille,    Ives,    Stern, 

Friedman,  Mercur,  Haythorn,  Smithies 88 

Obituary  Notice  of  Heinrich  Stern 101 

Constitution  and  By-Laws 103 

List  of  Members 107 


TRANSACTIONS  OF 

THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE, 

SECOND  SCIENTIFIC  SESSION 


DECEMBER  27  and  28,  1917, 

HOTEL  WILLIAM    PEXX,   PITTSBURGH,   PA. 


The  Congress  was  called  to  order  at  11  A.  M.,  December  27,  1917, 
by  the  President,  Dr.  Reynold  Webb  Wilcox. 

The  President  called  on  Dr.  John  A.  Lichty  to  welcome  the  mem- 
bers. 

Dr.  Lichty  :  Mr.  President ;  Members  of  the  American  Congress 
on  Internal  Medicine  and  Respected  Guests:  In  behalf  of  the  medi- 
cal profession  of  the  city  of  Pittsburgh  I  greet  you. 

We  are  conscious  of  the  honor  conferred  upon  us  by  the  presence 
of  the  distinguished  members  of  the  American  Congress  on  Internal 
Medicine.  It  would  be  a  pleasure  to  me  to  recount  the  aims  and 
accomplishments  of  the  congress,  as  well  as  to  speak  of  our  obliga- 
tions to  those  of  its  members  who  have  done  pioneer  and  advanced 
work  in  internal  medicine,  but  I  will  leave  that  to  be  spoken  of  by 
others,  and  shall  devote  my  few  allotted  moments  to  introduce  to 
you  things  medical,  which  are  characteristic  of  the  great  city  to 
which  you  have  come. 

Th  city  of  Pittsburgh  may  well  be  called  the  industrial  center  of 
the  world.  The  present  great  world  crisis  has  only  emphasized  this 
the  more.  Its  mills  and  manufactories  are  well  known.  It  is  an 
inland  town,  but  its  river  harbors  receive,  and  send  out  vessels 
whose  tonnage  is  equal  to  that  of  London  and  Liverpool  combined. 
To  us  this  is  a  well-worn,  but  agreeable  expression,  and  while  it  may 
not  at  present  stand  the  statistical  test,  it  at  least,  as  Mark  Twain 
says,  "sounds  well."  The  city  is  centrally  located.  Someone,  I 
do  not  know  whether  he  is  a  member  of  the  National  Geographical 
Society,  or  only  a  statistician  of  a  large  insurance  company,  has 
said  that  Pittsburgh  was  only  a  night's  ride  from  all  the  great  cities 
of  the  United  States.  The  railways  and  waterways  have  made  its 
transportation    facilities    unsurpassed.     With    such    resources    and 

7 


8        THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

facilities  this  city,  with  its  surrounding  community,  has  become  a 
veritable  workshop  for  the  whole  world.  The  relation  of  the  medi- 
cal profession  to  such  an  important  geographical  and  industrial 
center  has,  up  to  the  present  time,  been  largely  one  of  surgical 
repair,  and  the  city,  as  a  result,  can  boast  of  an  amount  and  quality 
of  surgery  which  can  scarcely  be  surpassed  in  any  other  city  of 
the  world.  It  would  be  a  pleasure  to  recount  the  names  of  men 
who  have  made  themselves  famous  here  in  the  practice  of  surgery 
during  the  past  fifty  years.  It  would  include  such  men  as  Walters, 
known  for  his  conservative  surgery ;  Sutton,  known  for  his  early 
introduction  of  the  principles  set  forth  by  Lister  and  Pasteur  and 
Lawson  Tait ;  the  McCanns ;  the  Dixons ;  and  the  brilliant,  beloved 
and  lamented  Stewart. 

While  internal  medicine  has,  in  a  way,  kept  pace  with  surgery, 
it  is  only  recently  that  it  has  come  into  its  own,  as  in  preventive 
medicine,  as  well  as  in  other  well  recognized  activites.  Pittsburgh 
formerly  had  the  highest  incidence  and  mortality  of  any  city  in  the 
United  States  in  typhoid  fever.  Through  the  direction  of  the  late 
Eugene  Matson,  bacteriologist  and  director  of  the  department  of 
public  health,  the  city  has  laid  unsurpassed  filtering  beds  so  that 
the  water  of  the  city  is  now  clean  and  typhoid  has  been  entirely 
eliminated. 

The  laboratories  of  the  city  are  now  directed  toward  the  preven- 
tion of  diseases  which  are  likely  to  occur  in  the  industries  which  are 
here  represented.  Internal  medicine  has  given  valuable  assistance 
in  the  elimination  of  the  smoke  nuisance.  Diseases  of  the  lungs  in 
relation  to  smoke  and  soot  have  been  particularly  studied  in  the 
laboratories  of  the  University  of  Pittsburgh  School  of  Medicine, 
and  in  many  other  ways  internal  medicine  has  set  about  to  bring 
to  pass  a  prevention  of  diseases,  accidents  and  calamities  which 
have  heretofore  prevailed  in  our  community. 

The  internists  of  the  city,  as  well  as  the  profession  at  large, 
appreciate  the  benefits  which  may  accrue  from  the  meeting  of  such 
a  body  as  the  Congress  on  Internal  Medicine  represents,  and  I 
again,  in  their  behalf,  welcome  you. 

Dr.  Thomas  F.  Reilly,  in  responding  to  the  address  of  welcome: 
Gentlemen  and  Members  of  the  Congress:  We  are  all  glad  to  be 
here.  Three  or  four  months  ago  it  was  feared  that  we  would  not 
be  able  to  meet  here,  as  the  conditions  that  the  war  has  brought 
about  have  made  it  necessary  for  many  learned  societies  to  close 


THE  AMERICAN  CONGRESS  OX  EXTERNAL  MEDICINE        9 

their  doors,  and  therefore,  they  were  not  ahle  to  assemble  here. 
Our  president  was  on  service  in  the  United  States  army,  and  mat- 
ters had  gone  so  far  that  we  were  even  warned  by  Dr.  Richards  that 
men  had  better  stay  at  home  and  help  to  conserve  matters  by  so 
doing.  We  were  also  warned  by  the  Pennsylvania  Railroad  that  we 
had  better  stay  at  home,  and  they  refused  to  sell  us  return  tickets. 
However,  in  spite  of  all  this  discouragement,  we  felt  that  this  meet- 
ing was  a  necessity  and  that  the  men  who  are  willing  to  go  to  all 
the  expense  and  trouble  that  is  entailed  by  travel  in  these  times, 
are  earnest  in  their  desire  to  attend  the  meeting.  We  are  glad  to 
be  in  Pittsburgh,  to  show  you  that  our  interests  are  not  parochial; 
that  these  meetings  belong  to  the  East  and  to  the  West.  Every  soci- 
ety that  moves  out  West  moves  toward  progress.  (xA.pplause.) 
Every  progressive  movement  lies  toward  the  West,  The  very  spirit 
of  terrestrial  magnetism  that  is  in  evidence  in  this  place,  the  fact 
that  we  are  surrounded  by  so  much  iron  and  steel  must  have  a 
physical  effect,  and  therefore,  indirectly,  a  mental  effect,  upon  us. 
Dr.  Lichty  has  pointed  out  that  Pittsburgh  is  a  suburb  of  Philadel- 
phia, so  far  as  scientific  matters  are  concerned.  There  are  numer- 
ous large  foundations  developing,  in  scientific  matters,  so  that 
Pittsburgh  is  awakening  to  new  scientific  life.  The  names  of 
Lichty,  Mercur,  and  Johnston  are  evidences  of  this.  They  have 
made  the  name  of  Pittsburgh  in  connection  with  science,  a  house- 
hold word. 

It  is  said  that  there  are  three  classes  of  millionaires — millionaires, 
multi-millionaires  and  Pittsburgh  millionaires.  I  feel  sure  from  my 
study  of  matters  in  this  city  that  one  may  say  there  are  three  classes 
of  internists — internists,  great  internists  and  Pittsburgh  internists. 

The  President  :  Last  spring,  when  I  was  ordered  on  duty  as  an 
officer  in  the  United  States  Army,  I  feared  that  it  would  be  impos- 
sible for  me  to  come  to  the  meeting.  I  asked  the  vice-president, 
Dr.  Bartley,  to  prepare  a  presidential  address  for  you.  Fortunately, 
I  am  able  to  be  with  you  to-day.  However,  Dr.  Bartley  has  pro- 
vided for  you  a  much  better  address  than  I  could  have  done. 

VICE-PRESIDENTIAL  ADDRESS 
By  DR.  E.  H.  BARTLEY 

Brooklyn 

Gentlemen  and  Members  of  the  Congress:  At  the  opening  of  this, 
the  second  meeting  of  the  Congress  of  Internal  Medicine,  I  con- 


10       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

gratulate  you  on  the  evidences  that  we  are  to  have  an  interesting 
and  instructive  session.  We  miss  the  faces  of  many  we  had  ex- 
pected to  have  with  us  to-day.  We  cannot  refrain  from  expressing 
a  feeling  of  sadness  for  the  occasion  which  has  called  away  thou- 
sands of  our  hrehren  to  the  colors  in  the  national  defense.  Not 
only  the  young  and  ambitious  but  those  of  reputation  and  years  of 
experience  of  which  the  Congress  is  largely  composed  have  gone  to 
help  to  win  this  war.  That  this  comparatively  young  organization 
must  be  affected  by  their  absence  was  to  be  expected.  It  was  to  be 
expected  that  the  attendance  would  be  decreased,  and  your  council 
seriously  considered  whether  it  might  not  be  advisable  to  omit  hold- 
ing the  congress  this  year.  We  hope  you  will  agree  with  us  that  it 
was  best  to  carry  out  the  program  in  spite  of  the  danger  of  the 
diminished  attendance  and  the  loss  of  enthusiasm  born  of  numbers. 
One  of  the  greatest  incentives  to  the  life  of  a  society  is  new 
members.  The  membership  of  this  Congress  is  large  and  it  should 
be  larger.  It  has  increased  about  one  hundred  since  the  last  meeting. 
It  should  be  doubled  during  the  next  year,  and  it  can  be  if  the 
fellows  will  all  do  their  part.  Any  qualified  physician  engaged  in 
the  practice  of  internal  medicine,  or  in  laboratory  research  pertain- 
ing to  it,  may  be  proposed  for  fellowship,  which  proposal  should 
be  made  in  writing  to  the  council  through  its  secretary.  It  is  very 
their  doors,  and  therefore,  they  were  not  able  to  assemble  here, 
desirable  that  the  fellows  should  be  careful,  in  proposing  candidates, 
to  select  physicians  in  their  localities  whose  reputation  and  char- 
acter are  above  reproach.  We  could  easily  double  our  membership 
by  circularizing  the  medical  profession  of  the  country,  but  this  is 
not  desirable  as  many  would  respond  who  might  be  undesirable,  or 
who  would  be  unknown  to  the  council,  and  they  would  have  no 
means  of  intelligent  selection  of  the  proper  ones.  The  council  must 
depend  largely  upon  the  good  judgment  of  the  fellows  for  the  selec- 
tion of  the  names  of  the  physicians  of  their  own  locality.  If  this 
plan  is  carried  out  the  congress  will  be  composed  of  selected  repre- 
sentative physicians  from  every  locality ;  a  fellowship  of  which  we 
shall  be  proud,  because  it  will  include  the  best  purely  medical  prac- 
titioners of  the  country.  This  will  make  this  congress  distinctively 
a  body  of  physicians  engaged  in  the  practice  of  internal  medicine,  or 
the  investigation  of  internal  pathological  conditions.  I  would  urge 
upon  every  fellow  to  use  his  best  endeavor  to  help  make  this  con- 
gress a  great  organization  by  securing  as  candidates  for  fellowship, 
the  best  physicians  of  his  acquaintance.     We  must  select  with  even 


THE  AM  URIC. IX  CONGRESS  ON  INTERNAL  MEDICINE       11 

greater  care  those  fellows  of  this  congress  whom  we  propose  for 
fellowship  in  the  college.  This  is  a  distinction  and  an  honor  which 
should  only  he  bestowed  for  some  notable  contribution  to  the  prog- 
ress of  internal  medicine,  or  to  the  public  good. 

It  will  then  mean  that  the  holder  of  this  certificate  has  done 
something  to  warrant  distinction,  and  we  believe  this  will  stimulate 
others  to  do  something  for  the  advancement  of  scientific  medi- 
cine. 

To  a  very  great  extent  the  progress  of  scientific  medicine,  except 
that  connected,  either  directly  or  indirectly,  with  military  medicine 
or  surgery,  is  at  a  stand  still,  throughout  the  world,  because  of  the 
war.  Everywhere  the  hospitals  and  the  laboratories  have  been 
hampered  by  the  loss  of  members  of  the  trained  staff.  Internes  are 
scarce  and  difficult  to  obtain,  and  much  of  their  work  is  being  done 
by  students  not  yet  graduated.  There  are  many  of  us  who  because 
of  age  and  other  unavoidable  circumstances  could  not  go  to  the 
front,  and  not  a  few  who  from  the  character  of  their  training 
should  not  go,  must  do  their  bit  at  home  among  the  civilians ;  not 
less  loyal,  not  less  willing  to  serve  their  country  in  spheres  no  less 
useful,  in  hospitals,  assisting  in  the  work  of  the  draft  boards,  or  in 
the  homes  of  their  several  communities.  The  aims  and  objects  of 
our  organization,  so  ably  set  forth  in  the  president's  address  of  a 
year  ago,  and  which  you  have  had  time  to  read  and  digest,  have  not 
changed  nor  will  they  change  with  the  changing  times.  As  the  man- 
hood of  the  world  is  being  so  heavily  drawn  upon  by  the  war,  the 
attention  of  the  medical  profession  should  be  turned  to  the  supreme 
importance  of  the  conservation  of  the  health  and  life  of  the  people 
left  at  home. 

The  lessons  of  the  selective  draft  have  impressed  upon  us  the 
necessity  of  working  for  the  betterment  of  the  race.  The  statistics 
of  some  of  the  local  boards  who  have  been  examining  recruits  for 
the  army  and  the  navy,  show  that  as  high  as  sixty  per  cent.,  or 
more,  of  the  men  who  came  before  them  were  unfit  for  the  service, 
according  to  the  standards  set.  This  was  a  surprise  to  most  of  us 
and  should  be  a  cause  of  concern  for  the  future  of  American  man- 
hood and  womanhood.  When  there  is  added  to  this  large  percen- 
tage of  physically  unfit,  the  maimed  and  shattered  remnants  of  these 
young  men  we  are  now  selecting  to  send  over  the  seas,  new  and 
serious  problems  must  be  met.  To  those  of  us  who  remain  in  civil 
life  these  problems  should  appeal  with  great  force.  These  lessons 
of  the  war,  or  more  properly,  the  preparation  for  war,  must  come 


12       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

home  to  us,  and  they  should  be  met  as  part  of  our  duty  to  the 
nation. 

There  is  already  a  great  field  for  the  medical  profession  in  efforts 
to  correct  the  defects  in  those  who  have  been  found  physically  unfit, 
so  far  as  these  defects  may  be  remedial,  and  more  especially  per- 
haps, in  those  who  will  soon  become  liable  to  call,  by  reason  of  age. 
Physical  defects  are  more  easily  corrected  in  early  life  than  at  draft 
age.  It  should  not  be  a  matter  of  pride,  that,  owing  to  the  laxity 
of  the  medical  profession  in  their  efforts  to  correct  the  physical 
defects  of  children,  the  boards  of  health  and  education  have  been 
compelled  to  take  the  matter  up  as  a  function  of  the  state,  or  of 
public  health.  Much  is  being  done  in  this  line  by  the  medical  inspec- 
tion of  schools,  and  by  the  periodical  examination  of  the  employees 
of  large  establishments  and  of  city  employees.  It  is  a  hopeful  sign 
that  this  matter  is  being  taken  up  by  labor  organizations.  It  cannot 
he  gainsaid  that  the  medical  profession  has  been  remiss  in  not 
taking  the  initiative  in  this  line  of  preventive  medicine.  They  have 
generally  left  it  to  the  boards  of  health,  or  to  life  institutes  or  in- 
surance societies. 

Is  it  not  an  opportune  time  and  the  duty  of  such  bodies  as  this, 
and  similar  organizations  of  representative  physicians,  to  undertake 
some  concerted  action  looking  toward  the  physical  improvement  of 
the  masses  of  the  people?  The  time  is,  or  ought  to  be,  that  the 
practice  of  medicine  should  not  be  confined  to  the  diagnosis  and 
treatment  of  the  diseases  of  the  acutely  ill,  but  should  include  all 
measures  for  the  betterment  of  the  race;  certainly  to  the  careful 
supervision  of  the  health,  development  and  defects  of  the  young  of 
pre-school  age,  before  they  come  under  the  supervision  of  the  school 
authorities.  It  has  been  stated  by  competent  authorities  that  there  are 
in  the  public  schools  of  Xew  York  City  more  than  20,000  children 
suffering  with  serious  heart  lesions.  It  must  be  admitted  that  many 
of  these  if  properly  handled  before  the  age  of  six  years,  may  be 
converted  from  serious  into  at  least  benign  conditions.  As  ex- 
amples of  other  remedial  conditions  met  with  in  early  life,  we  may 
mention  the  various  focal  infections;  of  the  middle  ear,  tonsils, 
nasal  sinuses,  teeth,  and  intestine;  defective  nutrition,  defective 
growth,  deformities,  defective  or  abnormal  endocrinous  glands, 
tuberculous  infection  and  lues.  It  is  the  general  practitioner  and 
the  internist,  not  the  specialist  who  must  primarily  either  deal  with 
these  conditions  or  be  responsible  for  their  neglect.  Every  internist 
has  these  physically  defective  children  brought  to  him  for  consulta- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      13 

tion  and  he  cannot  entirely  shift  the  responsibility  upon  the  pedi- 
atrist. 

The  most  vulnerable  age  is  the  pre-school  age.  Most  of  the 
tubercular-infections  and  many  of  the  organic  heart  diseases  begin  at 
this  time.  It  is  at  this  age  that  those  nutritional  defects  begin  which 
are  apt  to  continue  to  later  years  and  affect  the  efficiency  of  the 
future  man  or  woman.  In  this  connection,  there  is  no  more  im- 
portant held  of  investigation  than  that  which  is  claiming  the  atten- 
tion of  some  biological  chemists  to-day,  relating  to  the  study  of  the 
effects  of  different  foodstuffs  on  the  development  and  growth  of 
animals.  There  is  a  great  need  of  a  better  understanding  of  the 
principles  and  practice  of  feeding  the  young,  so  as  to  promote 
growth  and  development  to  the  best  advantage.  We  have  not 
developed  the  art  of  feeding  the  human  animal  to  the  extent  that 
the  agriculturalist  has  that  of  feeding  farm  animals.  What  we  have 
already  learned  from  recently  conducted  feeding  experiments  has 
given  us  an  explanation  of  the  etiology  of  a  number  of  diseases, 
now  known  as  deficiency  diseases,  such  as  scurvy,  berri  berri,  pel- 
lagra, etc.  We  have  reason  to  hope  that  this  line  of  inquiry  will 
teach  us  how  we  may  overcome  the  handicap  of  a  poor  heredity  by 
proper  application  of  the  principles  of  feeding,  with  perhaps,  the 
discovery  of  an  active  principle  promoting  growth  which  can  be 
added  to  the  ordinary  diet.  Some  efforts  have  been  made  to  find 
such  substance,  with  very  limited  success,  in  the  internal  glands. 
Investigations  made  by  the  New  York  Board  of  Health  show  that 
from  eight  to  twelve  per  cent,  of  the  children  in  the  schools  of  that 
city  suffer  from  such  a  degree  of  malnutrition  as  to  need  supervision, 
in  their  opinion.  This  represents  about  125,000  school  children  in 
that  city  whose  nutrition  needs  supervision.  That  this  is  not  due 
entirely  to  the  high  cost  of  living  is  shown  by  the  fact  that  the 
figures  are  higher  for  1916  than  for  1917.  Many  of  these  children 
will  grow  up  to  inefficient  men  and  women.  The  hope  for  the 
citizenship  of  the  future  of  this  country  is  not  in  the  children  of 
the  educated  and  wealthy  classes,  for  they  are  not  prolific  in  the 
production  of  their  kind.  It  is  the  children  of  the  so-called  labor- 
ing classes,  and  the  ignorant  foreign-born  parents  who  fill  our  public 
schools ;  or  those  who  are  least  able  to  appreciate  these  facts  and 
their  importance.  It  is  these  children  who  will  make  up  the  majority 
of  the  future  men  and  women  of  America.  Whether  they  maintain 
the  traditions  of  the  past  will  depend  upon  how  well  the  medical 
profession,  the  schools  and  churches  do  their  patriotic  duty  by  them. 


14       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

This  war  has  made  this  country  the  dominant  nation  of  the  world. 
When  this  crisis  is  past,  we  must  be  ready  to  meet  the  great  indus- 
trial war  that  is  to  follow.  Europe  will  look  to  this  country  for 
men  and  material  resources  to  help  them  to  reconstruct  and  rehabili- 
tate their  countries.  Shall  we  be  equal  to  the  task?  I  believe  we 
shall,  but  it  will  depend  upon  the  energy  and  efficiency  of  our 
people,  east,  west,  north  and  south.  Efficiency  depends  on  good 
health.  Unless  this  war  should  terminate  very  soon,  there  will  be 
a  new  and  very  great  task  imposed  upon  the  medical  profession  of 
this  country,  in  the  reconstruction  of  the  men  returning  to  us  from 
the  trenches.  These  will  require  the  neurologist  and  internist  as 
well  as  the  orthopedist.  There  is  a  great  work  ahead  of  us,  and 
much  of  it  will  be  unremunerative,  and  which  we  shall  accept  as  a 
national  duty.  We  cannot  afford  to  be  regarded  as  slackers  in  this 
duty.  We  have  only  words  of  praise  for  those  of  our  profession 
who  have  so  nobly  and  with  great  personal  sacrifice,  enlisted  in  the 
national  service.  The  loyalty  of  those  who  remain  at  home  is  under 
observation  and  on  trial. 

Dr.  R.  W.  Wilcox  :  The  problem  of  the  organization  of  a  soci- 
ety of  internists  has  been  an  important  one  to  the  medical  profession. 
There  is  one  member  of  this  society  who  thought  of  this  and 
planned  it.  and  worked  day  and  night  toward  its  organization,  for 
years  before  this  society  was  born.  You  all  know  him,  gentlemen ; 
I  am  sure  that  I  need  not  make  any  further  comment  in  regard  to 
the  work  of  our  secretary-general. 

ADDRESS  OF  THE  SECRETARY-GENERAL, 

By  DR.  HEIXRICH   STERN 
New    York    City 

Gentlemen:  I  came  here  to-day  to  show  my  interest  in  the  society 
as  I  think  it  is  necessary  to  push  the  organization  along  this  year. 
I  was  told  that  there  would  not  be  a  meeting,  but  I  insisted  upon 
it,  although  the  men  who  were  on  the  committee  were  in  some  trepi- 
dation. They  said  that  the  Pennsylvania  Railroad  would  not  sell 
return  tickets  and  asked  me  to  call  the  arrangements  off.  However, 
I  feel  that  the  meeting  is  necessary  at  this  time ;  we  are  only  begin- 
ning to  be  involved  in  the  war,  and  next  year  we  may  be  much  more 
deeply  in,  and  we  physicians  have  to  be  prepared  to  see  it  through. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      15 

This  year  it  might  appear  that  we  had  not  done  much,  but  the 
council  has  had  ten  meetings.  We  have  added  to  our  list  125  to  130 
new  members,  and  1  feel  that  that  is  very  encouraging  for  a  new 
organization.  We  muster  about  450  members  now.  That,  of  itself, 
shows  that  the  congress  on  internal  medicine  was  a  necessity.  The 
work  last  year  was  largely  left  to  individuals,  and  I  may  say  that 
Drs.  Pottinger  and  Aaron  did  the  hulk  of  the  work  in  getting  mem- 
bers for  our  organization.  Dr.  Pottinger  is  a  horn  agitator.  He 
has  seen  a  great  number  of  people,  and  we  have  not  had  to  advertise 
as  the  College  of  Surgeons  has.  Dr.  Aaron  has  made  great  per- 
sonal efforts  and  has  got  us  the  best  men  of  the  profession. 
During  the  year,  the  secretary  has  taken  upon  himself  to  publish 
the  transactions.  Dr.  Cornwall  has  rendered  the  most  loyal  and 
effective  assistance,  and  thanks  are  due  to  him,  more  than  to  me,  for 
the  results.  If  there  are  any  special  questions  that  anyone  wishes 
to  put  to  the  secretary,  in  regard  to  either  the  American  Congress  on 
Internal  Medicine  or  the  American  College  of  Physicians,  I  shall 
be  more  than  glad  to  answer  them. 

Dr.  R.  W.  Wilcox:  Judging  from  the  work  of  the  committee  on 
arrangements,  it  is  not  a  matter  of  great  importance  that  we  could 
not  get  return  tickets.  We  appreciate  the  hospitality  of  Pittsburgh, 
and  we  are  ready  to  stay  here.  We  will  now  listen  to  the  report 
of  the  treasurer. 

REPORT  OF  THE  TREASURER 

Dr.  A.  Caille:  The  treasurer  would  like  to  add  a  remark  on 
the  reading  of  his  report.  During  the  first  months  of  organizing  a 
new  society,  the  expenses  are  enormous,  compared  with  what  will 
occur  later.  Many  expenses  have  to  be  met  that  will  not  happen 
again.  The  society  has  met  all  these  unusual  expenses  and  finds 
itself  upon  a  firm  financial  basis. 

Dr.  Thomas  Reilly  :  Dr.  Joseph  H.  Byrne  and  I  have  audited 
the  report  and  find  it  correct. 

Dr.  R.  W.  Wilcox:  And  you  have  certified  to  that  effect? 

Dr.  Reilly  :  Yes. 


16      THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Dr.  R.  W.  Wilcox  :  In  every  society  death  must  come,  and  dur- 
ing the  past  year  some  of  our  members  have  left  us.  Dr.  Edward  E. 
Cornwall  will  present  this  subject  more  fully  to  you. 

Dr.  Cornwall  :  The  members  who  have  died  are :  Dr.  Claude  L. 
Wheeler,  editor  of  the  New  York  Medical  Journal,  for  many  years, 
a  man  of  delightful  personality  and  very  well  known  in  the  pro- 
fession. Dr.  Henry  L.  Coit,  of  Newark,  whose  name  is  intimately 
connected  with  movements  toward  the  furtherance  of  infant  wel- 
fare, and  who  was  one  of  the  first  to  advocate  and  insist  upon  cer- 
tified milk.  Dr.  LeRoy  Satterlee,  who  was  widely  known  and 
much  esteemed.  He  was  in  practice  as  an  internist  for  many  years 
and  was  connected  with  the  teaching  staff  of  the  New  York  Dental 
Institute. 

The  president  announced  that  the  next  order  of  business  was  the 
election  of  officers,  and  that  the  council  of  the  congress,  acting  ac- 
cording to  the  by-laws,  and  as  a  nominating  committee,  presented 
the  following  nominees  for  office,  and  they  were  unanimously  elected 
for  the  year  1918-1919. 

President,  Dr.  Glentworth  R.  Butler. 

Vice-President,  Dr.  Elias  H.  Bartley. 

Treasurer,  Dr.  Augustus  Caille. 

Assistant  Secretary,  Dr.  Joseph  H.  Byrne. 

Council :  Drs.  Reynold  Webb  Wilcox,  H.  Enos  Tuley,  Charles 
E.  deM.  Sajous,  Wm.  H.  Mercur  and  Thomas  E.  Satterthwaite  in 
the  Class  of  1922,  and  Dr.  Frederick  Tice  in  the  Class  of  1918. 

Notice  of  an  amendment  to  the  constitution  was  presented  to 
the  society,  to  be  acted  upon  at  the  next  annual  meeting.  This 
amendment,  offered  by  Dr.  Bartley,  was  in  effect  that  a  second  vice- 
president  should  be  elected  as  one  of  the  officers  of  the  congress. 

Dr.  Caille  then  moved  that  a  vote  of  thanks  be  tendered  to  Dr. 
Wilcox  for  the  efficient  and  dignified  services  he  had  rendered  to 
members  of  the  association,  as  their  president.  He  felt  personally 
that  he  would  very  much  miss  Dr.  Wilcox  in  this  capacity.  Dr. 
Satterthwaite  seconded  this  motion  and  a  rising  vote  of  thanks  was 
tendered. 

Dr.  R.  W.  Wilcox:  Gentlemen,  I  wish  to  thank  you  for  your  ex- 
pression of  appreciation.  I  came  into  this  organization  at  the  in- 
stigation of  the  secretary-general  and  I  esteem  it  a  great  honor  to 
have  been  your  president  for  two  terms.     Whatever  energy  I  have 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE       17 

put  into  my  task  I  have  regarded  as  only  what  the  organization  well 
deserved;  whatever  talents  I  have  shown  in  the  execution  of  my 
duties  I  have  been  glad  to  devote  toward  making  a  success  of  the 
society.  I  feel  that  in  this  way  I  may  have  been  of  service  to  my 
profession  and  to  my  country. 

ROENTGENOLOGY  AND  THE  INTERNIST 
By  CHARLES  D.  AARON 
Detroit,    Mich. 

The  days  of  experimentation  with  the  roentgen  ray  are  far  from 
past.  No  sooner  has  a  new  technic  been  devised  for  certain  manipu- 
lations, or  an  instrument  perfected,  than  fresh  ideas  and  discoveries 
demand  recognition,  and  what  is  considered  a  great  success  to-day 
may  be  superseded  to-morrow.  Roentgenology  is  still  in  an  active 
stage  of  evolution  and  bids  fair  to  remain  so  for  a  considerable 
time  to  come,  until,  perhaps,  some  genius  shall  discover  the  very 
nature  of  the  rays  and  solve  on  a  scientific  basis  what  must  now  be 
empirically  gathered  from  laborious  experimentation  and  observa- 
tion. 

However,  it  is  gratifying  to  record  the  fact  that  the  rapid  advances 
which  have  been  accomplished  in  the  evolution  of  this  new  science, 
from  its  crude  inception  to  the  comparative  perfection  of  the  pres- 
ent day,  have  given  it  a  quality  of  positiveness  which  renders  it  a 
valuable  aid  in  both  diagnosis  and  treatment. 

In  the  early  period  of  the  roentgen  era,  some  claims  were  made 
for  the  ray  which  could  not  be  substantiated  and  which  were 
promptly  discarded,  surviving  only  in  the  minds  of  pseudo-scientists 
who  have  no  standing  in  the  profession.  Having  successfully 
passed  through  the  storm  and  stress  of  its  early  history,  the  science 
has  acquired  a  definite  significance  which  commands  universal  pro- 
fessional respect.  Colleges  have  introduced  the  study  of  the  sub- 
ject, and  the  laboratory  of  Roentgen  diagnosis  and  treatment  has 
become  one  of  the  essentials,  not  only  of  every  well-equipped  hos- 
pital and  kindred  institution,  but  even  of  methodic  modern  office 
practice.  The  academic  standing  of  roentgenology  is  assured,  and 
no  less  its  practical  value.  Still,  its  service  to  the  medical  profes- 
sion is  not  what  it  might  be  with  more  perfect  technic  and  a  better 
correlation  between  the  science  of  roentgenology  and  the  science  of 
medicine. 


18       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

One  of  the  stumbling  blocks  that  hinder  the  progress  of  roentgen- 
ology is  the  lack  of  uniformity  in  technical  details.  For  example, 
there  is  as  yet  no  generally  accepted  standard  test  meal  preceding 
the  roentgenologic  observation  of  the  gastrointestinal  tract.  Not 
only  do  the  American,  English,  French,  German  and  other  test  meals 
differ  for  apparently  no  other  reason  than  that  they  have  been  de- 
vised or  promulgated  by  a  leader  to  whom  allegiance  is  naturally 
rendered  for  racial  or  national  reasons,  but  various  authorities  in 
the  same  country  have  been  unable  to  agree  upon  a  standard.  The 
matter  of  expense  and  also  the  idiosyncrasy  of  the  patient  are 
factors  in  the  case,  but  not  to  such  an  extent  as  to  render  an  agree- 
ment on  a  desirable  standard  impossible.  The  value  of  roentgeno- 
graphic  examination  consists  not  only  in  the  information  it  furnishes 
to  the  examiner  in  an  individual  case,  but  also,  and  even  to  a  greater 
extent,  in  the  possibility  of  comparing  results  in  a  large  number  of 
cases  which  have  been  examined  by  different  men  in  different  offices, 
institutions  and  countries.  Such  a  comparison  is  impossible  unless 
a  standardized  test  meal  is  used,  together  with  a  standardized 
technic  of  administration.  Want  of  standardization  is  one  of  the 
greatest  drawbacks  in  the  evolution  of  a  new  science,  and  although 
the  roentgenologic  fraternity  admits  the  fact,  the  conditions  are  not 
likely  to  be  changed  as  long  as  the  leaders,  who  have  set  up  what 
they  consider  standards  for  themselves,  expect  others  to  adopt  them 
and  are  unwilling  to  compromise. 

This  may  be  and  probably  is  due  to  their  meager  experience  with 
test  meals  other  than  their  own,  inasmuch,  as  each  roentgenologist 
will,  unless  actuated  by  broader  motives,  adhere  to  his  own  method 
and  refuse  to  experiment  with  others.  But  is  it  too  much  to  hope 
that  recognized  authorities  will  ultimately  allow  themselves  to  be 
convinced  by  demonstrable  facts,  to  sink  their  personal  proclivities 
and  to  settle  upon  a  standard  which  a  competent  majority  proclaims 
to  be  acceptable?  The  advantage  in  obtaining  comparable  results 
for  the  furtherance  of  the  practical  usefulness  of  the  art  ought  to 
carry  sufficient  weight  with  it  to  lead  them  to  agree  upon  uniform 
procedures  in  this  respect. 

Another  reason  why  internists  have  looked  askance  at  the  intru- 
sion of  roentgenology  upon  the  domain  of  diagnosis  is  that  they 
rightly  objected  to  the  idea  of  roentgenologic  examinations  displac- 
ing the  ordinary  routine  diagnostic  methods.  There  may  have  been 
a  trend  in  that  direction  on  the  part  of  early  roentgenologists  who 
allowed  themselves  to  be  swayed  by  youthful  enthusiasm,  but  such 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE       19 

is  fortunately  no  longer  the  ease,  and  the  specialists  of  the  new 
science  do  not  claim  to  render  any  but  supplementary  service  in 
diagnosis.  At  the  same  time,  it  should  be  admitted  that  in  some 
conditions  the  roentgen  ray  reveals  more  pathology  than  the  clinical 
diagnosis,  provided  the  interpretation  of  the  shadow  pictures  is 
correct.  In  incipient  tuberculosis,  for  instance,  the  early  signs  may 
be  roentgenologically  detected  while  clinical  symptoms  are  as  yet 
absent.  Cases  of  osteitis  fibrosa  cystica  have  been  reported  in 
winch  the  roentgenograms  were  so  characteristic  that  it  would  have 
been  difficult  to  mistake  them,  and  yet  the  diagnosis  could  not  have 
been  made  from  the  clinical  pathologic  picture.  All  roentgenologic 
findings  are,  however,  only  placed  in  the  hands  of  the  clinician  for 
what  they  may  be  worth.  They  will  serve  to  direct  his  attention 
to  the  probable  presence  of  conditions  which  have  not  yet  advanced 
far  enough  to  produce  clinical  symptoms.  But  in  view  of  the  fact 
that  the  roentgen  ray  furnishes  only  shadows  which  have  to  be  in- 
terpreted, and  not  complete  reproductions  of  actual  pathologic  facts, 
no  roentgenologist  worthy  of  the  name  would  think  of  suggesting 
that  his  findings  should  take  the  place  of  a  regular  clinical  examina- 
tion. 

Another  point  I  would  emphasize  as  a  truth  beyond  all  possible 
cavil  is  that  a  knowledge  of  pathology  is  an  absolute  necessity  for 
making  a  roentgenologic  examination  and  interpreting  the  shadows 
correctly ;  and  that  accuracy  in  diagnosis  by  this  means  requires  an 
equally  thorough  clinical  knowledge,  because  the  roentgenographic 
findings  must  be  correlated  with  the  clinical  history  and  the  present 
condition  of  the  patient.  The  right  interpretation  of  the  fluoroscope 
or  plate  is  dependent  upon  this  knowledge.  How  is  the  roentgenolo- 
gist to  have  a  clear  mental  perception  of  the  changes  consequent 
upon  disease,  unless  pathology  is  an  open  book  to  him?  It  is  with 
roentgen  ray  as  with  the  microscope ;  both  reveal  the  condition 
of  tissues  in  health  and  disease,  but  the  revelation  cannot  be  inter- 
preted with  any  pretence  to  usefulness,  except  in  the  light  of  accurate 
knowledge  of  larger  subjects — anatomy,  physiology,  histology,  and 
pathology. 

Similarly,  it  is  not  too  much  to  ask  that  the  skilful  roentgenolo- 
gist should  also  be  a  good  clinician.  Indeed,  all  these  demands  have 
now  been  recognized  for  some  time  by  leading  specialists  in  the  art. 
But  there  are  still  survivals  from  early  times,  when  roentgenography 
was  likened  to  photography  and  when  nothing  was  supposed  to  be 
required  of  the  "artist"  but  the  ability  to  "take  a  picture."     These 


20       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

times  are  gone,  and  the  present  arraignment  is  only  intended  to  em- 
phasize the  fact  that  the  roentgenologist  who  is  insufficiently  versed 
in  the  intricacies  of  the  anatomical,  medical  and  surgical  require- 
ments, or  who  is  inexact  in  the  practical  application  of  his  knowl- 
edge, must  yield  the  field. 

These  demands,  of  course,  do  not  apply  to  the  assistants  employed 
in  a  large  roentgenologic  laboratory  whose  principal  requirements 
are  a  technical  knowledge  of  the  instruments  and  apparatus  they 
are  expected  to  handle.  In  other  words,  there  are  two  phases  to  be 
considered  in  the  problem  of  turning  roentgenology  to  successful 
account :  The  brain  of  the  physician  who  directs  the  proceedings  and 
interprets  the  findings,  and  the  technician  who  carries  out  the  in- 
structions. This  situation  naturally  suggests  the  desirability  of 
every  physician  being  able  to  act  as  his  own  roentgenologist  where, 
as  a  matter  of  fact,  very  few  clinicians  have  a  sufficient  knowledge 
of  the  roentgenologic  theory  and  practice  to  justify  their  attempting 
an  interpretation  of  a  series  of  plates. 

To  be  sure,  there  are  many  instances  in  which  interpretation  is 
easy.  But  such  instances  should  not  mislead  us  into  indolent  cre- 
dulity. Gastric  pathology  is  a  case  in  point.  It  is  not  difficult  to 
recognize,  in  autopsy  or  at  operation,  definite  lesions  or  pathologic 
alterations,  such  as  an  hour-glass  stomach,  perforating  gastric  ulcer, 
or  pyloric  obstruction ;  but  in  the  clinic  identical  symptoms  may  be 
due  to  stomach  disease  or,  for  example,  to  cholecystitis  or  chronic 
appendicitis.  Therefore,  the  primary  lesion  must  be  found,  if  pos- 
sible, and  it  is  the  business  of  the  roentgenologist  to  make  out  cer- 
tain identifying  marks  that  will  indicate  the  cause  of  the  patient's 
symptoms.  Some  of  his  problems  may  indeed  be  difficult,  for  the 
pathologic  process  may  be  in  the  gall  bladder,  in  the  appendix,  or 
in  the  colon.  Here  he  can  show  his  experience  as  an  observer,  and 
also  his  technic  in  application. 

All  this  points  to  the  supreme  desideratum — standardization. 
Both  the  methods  and  the  technic  need  it,  the  more  so  since 
Roentgen  diagnosis  has,  after  all,  its  limitations  as  well  as  its  possi- 
bilities. It  is  to  be  regretted  that,  as  none  other,  this  new  specialty 
allows  such  diversities  in  technic  and  such  variations  in  the  conclu- 
sions from  the  findings. 

Many  cases  have  been  observed  which  illustrate  the  need  of  a  uni- 
versal technic,  as  a  diagnosis  based  on  roentgenograms  obtained  by 
one  technic  is  apt  to  be  discredited  by  a  subsequent  roentgenogram 
of  the  same  case  made  by  a  different  man  and   with  a  different 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      21 

technic.  This  drawback  is  to  a  certain  extent  overcome  by  ex- 
perienced roentgen  men  stating  in  their  reports  the  details  of  the 
technic,  the  position  of  the  patient  and  of  the  roentgen  tube, 
together  with  all  the  other  incidentals ;  but  in  the  first  place, 
his  precaution  is  in  many  cases  ignored,  and  in  the  second  place  the 
necessity  for  it  would  largely  disappear,  at  least  in  routine  examina- 
tions, if  a  universal  technic  were  employed.  The  successful  appli- 
cation of  the  roentgen  art  is  largely  dependent  on  the  relative  posi- 
tion of  patient  and  roentgen  tube,  and  the  visualization  of  certain 
shadows  depends  upon  this  very  fact,  as  for  instance  in  the  localiza- 
tion of  foreign  bodies,  gallstones,  fractures  and  dislocations  ;  thus 
the  individual  skill,  ingenuity  and  experience  of  the  roentgenologist 
must  determine  the  technic.  The  personal  equation  is  and  will  re- 
main a  deciding  factor  in  the  success  or  failure  of  a  roentgeno- 
graphic  examination.  However,  this  does  not  do  away  with  the 
further  fact  that  even  the  work  of  the  expert  would  be  more  ex- 
pert, and  the  altruistic  value  of  his  work  to  the  community  im- 
measurably enhanced,  were  the  general  trend  of  his  work  based  on 
standardized  principles,  so  that  the  results  could  be  intelligently 
scrutinized,  compared  and  repeated. 

Standardization  is  required  in  many  other  important  points  con- 
nected with  roentgenology  in  addition  to  test  meals  and  the  position 
of  the  patient  under  examination,  but  the  object  of  this  paper  is 
rather  to  call  attention  to  this  requirement  on  general  principles 
than  to  go  into  technical  details.  Among  the  latter  may  be  men- 
tioned the  deplorable  absence  of  a  standard  of  measuring  the  dosage, 
and  the  quantity  and  quality  of  the  rays  to  be  employed  in  a  given 
case.  The  attempts  have  been  many,  and  the  difficulty  of  the  task 
is  admitted,  but  its  solution  is  no  nearer  to-day  than  it  was  years 
ago,  and  there  is  no  tangible  result  in  sight.  Similarly,  attempts 
have  been  made  to  standardize  the  application  of  the  rays  over 
definite  areas  of  the  body,  especially  in  deep  application  for  thera- 
peutic purposes,  to  make  sure  that  no  one  part  of  the  body  receives 
more  or  less  than  its  intended  share  in  repeated  treatments.  While 
suggestions  have  been  made  along  this  line  from  time  to  time,  the 
roentgenologic  section  of  the  profession  is  slow  in  discussing,  accept- 
ing or  rejecting  them  with  a  view  to  arriving  at  anything  like  stand- 
ardized procedures.  The  general  feeling  which  prompts  them  to 
adopt  an  attitude  of  "masterful  inactivity"  or  "watchful  waiting" 
is  not  due  to  indolence  or  apathy,  but  probably  to  a  realization  of  the 
fact  that  their  experience  has  not  yet  sufficiently  matured  to  justify 


22       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

the  adoption  of  more  or  less  irrevocable  plans.  But  this  very  con- 
sideration should  be  an  incentive  to  increase  and  perfect  their  ex- 
perience, and  this  much-desired  result  can  only  be  won  by  a  uni- 
versal comparison  of  results  and,  consequently,  by  standardization 
of  the  important  steps  bound  up  in  the  practical  application  of  the 
art. 


ROENTGEN  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST 

By  GEO.  C.  JOHNSTON 
Pittsburgh,  Pa. 

The  subject  indicated  in  the  title  of  this  paper  is  so  extensive  that 
it  would  be  impossible  to  more  than  touch  lightly  on  the  various 
points  in  the  time  allotted  to  this  purpose. 

In  making  an  examination  of  the  chest,  it  is  always  wise  to  pro- 
ceed according  to  a  certain  routine,  in  order  that  one  may  not  be 
misled  by  the  history  of  the  patient  or  other  elements  in  overlook- 
ing some  important  point  upon  which  the  entire  diagnosis  may  rest. 

In  our  clinical  work  we,  therefore,  make  it  a  rule  in  every  ex- 
amination of  the  thorax  to  note  the  following  points: 

a.  Heart — size,  shape,  position  and  action 

b.  Aorta — size,  position,  dilatation,  aneurysm,  calcification 

c.  Lungs — apices. 

1.  Illumination  of  enforced  inspiration  (light  reflex) 

2.  Relative  distensibility 

d.  Diaphragm 

1.  Degree  of  visibility 

2.  Curvature 

3.  Excursion  (equal  bilaterally?) 

4.  Fixation   (adhesions) 

e.  Mediastinum 

1.  Size 

2.  Shape 

3.  Presence  of  opaque  bodies 

4.  Tumors 

5.  Aneurysm 

6.  Adenopathy 

7.  Persistent  thymus 

Following  this  general  survey,  we  now  proceed  to  examine  in  de- 
tail.    We.  look  first  for  the  shadow  of  the  trachea,  which  upon  the 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      23 

screen  appears  as  a  bright  band  anterior  to  the  median  line  and 
fading  behind  the  aortic  arch.  If  there  be  any  deviation  of  the 
tracheal  shadow,  we  desire,  at  once,  to  know  why  the  displacement 
and  suspect  pressure,  which  requires  explanation. 

Further  down  we  notice  the  hilus  shadows  on  either  side,  well 
marked  on  the  right  and  hidden  on  the  left  behind  the  heart,  cast 
by  the  bronchi  and  great  vessels,  and  the  numerous  lymphathics 
about  the  roots  of  the  lungs. 

Toward  the  periphery  the  lungs  become  more  transparent,  but 
we  are  able  to  trace  out  the  shadows  cast  by  the  broncheal  tree  with 
its  accompanying  lympathics  and  shadows.  If  the  alveoli  are 
healthy  in  all  portions  of  the  lungs,  lungs  will  be  equally  translucent. 

Increased  radiability  showing  bright  upon  the  screen  and  black 
upon  the  plate  may  indicate  a  tuberculous  cavity  or  a  bronchiectasis, 
dilatation,  emphysema  or  pneumothorax,  while  decreased  radiability 
might  be  caused  by  a  pneumonia,  lung  suppuration,  thickened  pleura 
or  pneumonokoniosis,  syphilis  or  malignant  disease. 

A  decreased  area  of  radiability  surrounding  a  more  or  less  circu- 
lar area  of  increased  radiability  would  suggest  an  abscess  cavity. 

In  an  examination  of  the  lungs  we  study  not  only  lung  tissue,  but 
the  pleural  cavity  and  the  diaphragm.  Thus  in  the  study  of  an 
instance  of  lobar  pneumonia  by  means  of  the  x-ray  (which  study  is 
being  made  and  more  in  the  military  hospitals  abroad),  we  might 
expect  to  find  the  following  phenomena  present. 

FIRST  STAGE 

Lung.  Light  shadow  over  one  lobe 
Pleura.  Increase  in  pleural  shadow 
Diaphragm.     Visibility  lowered  and  excursion  limited 

SECOND  STAGE 

Lung.     Dense  shadow  of  one  or  more  lobes 
Pleura.     Increase  in  pleural  shadow 
Diaphragm.     Excursion  and  visibility  lost 

THIRD  STAGE 

Lung.  Irregular,  ill-defined  areas  of  density  involving  a  lobe  or 
lobes 


24       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Pleura.     Clearing 

Diaphragm.     Excursion  and  visibility  returning 

The  above  table  is  taken  from  Crane's  excellent  article  on  the 
skiascopy  of  the  chest  which  appeared  more  than  fifteen  years  ago. 
I  mention  this  point  in  order  that  you  may  see  that  there  is  nothing 
new  in  the  examination  of  the  chest  by  means  of  the  x-ray. 

Now  let  us  consider  for  a  moment  the  appearances  which  we 
might  expect  in  a  broncho-pneumonia.  We  will  find  first  that  both 
lungs  are  affected,  irregular  shadows  over  both  lungs,  visibility  of 
diaphragn   slightly  impaired,   excursion  of   diaphragm  unimpaired. 

In  pulmonary  oedema,  on  the  contrary,  the  screen  appearances  of 
the  thorax  is  very  unusual.     If  the  oedema  is  extensive  we  will  find 

1.  Heart  and  aortic  shadow  lost 

2.  Diaphragm  shadows  lost 

3.  All  chest  landmarks  lost 

Emphysema  will  show  an  increased  radiability  of  the  lung  on  one 
or  both  sides  confined  to  the  emphysematous  areas.  Atelectasis, 
due  to  blocking  of  the  bronchus,  perhaps  from  foreign  body,  will 
show  a  decreased  radiability  of  the  portion  of  the  lung  extending 
to  that  part  of  the  bronchial  tree,  the  main  trunk  of  which  is  blocked. 

LUNG  TUMORS 

The  primary  tumors  of  the  lung  most  often  seen  are  the  sarcomata 
and  the  appearances  are  very  striking.  In  the  advanced  stages  one 
or  several  globular  masses  of  rather  uniform  density  may  be  seen 
to  invade  the  lung  tissue.  The  tumor  wall  is  sharply  defined,  the 
demarcation  between  tumor  and  lung  being  easily  observed.  This 
is  in  contradistinction  to  carcinoma  of  the  lung.  The  remainder  of 
the  lung  tissue  may  be  perfectly  healthy.  These  tumors  attain  con- 
siderable size,  from  one  to  four  inches  in  diameter,  and  may  give 
rise  to  very  few  pulmonary  symptoms,  unless  so  situated  as  to  make 
pressure  on  some  of  the  great  vessels. 

Carcinoma  of  the  lungs,  usually  secondary  and  quite  prone  to 
produce  metastases  from  the  breast  or  prostate,  occur  frequently 
and  give  an  appearance  of  very  light  lung  suppuration,  but  without 
the  bronchial  marking.  The  lung  tissue  involved  resembles  the 
body  tissue  as  in  periosteal  sarcoma.  The  disease  appears  at  the 
hilus  and  radiates  out  into  the  parenchyma  of  the  lung.  In  early 
stages  it  appears  as  thoroughly  interlobular,  but  later  may  involve 
the  lung  very  extensively. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      25 

Diseases  of  the  pleura  are  quite  easily  diagnosed  by  means  of  the 
x-ray.  This  is  the  first  axiom.  A  visible  pleura  is  always  patho- 
logical.    We  may  differentiate  by  means  of  the  x-ray. 

1.  Acute   pleuritis 

2.  Acute  pleuritis  with  effusion 

3.  Chronic  pleuritis 

4.  Empyema 

5.  Hydro-pneumothorax 

6.  Pyo-pneumothorax 

7.  Interlobular  pleurisy 

PLEURISY    WITH    EFFUSION 

a.  Lung  retracts. 

b.  Dark    shadows    with    sharp    upper    border,    which    border 

changes  shape  with  position  of  patient. 

(Only  true  with  incomplete  effusions.) 
Pyothorax  same  as  above  except  darker  shadow. 
In  complete  left  pleural  effusion : 
Heart  displaced  to  right. 
Diaphragm  shadow  effected  in  erect  posture,  but  can  be  seen 

if  you  can  place  patient  in  Trendelenburg  position. 
Dark  shadows  rarely  extend  to  apex. 
Differential  diagnosis  between  complete  pneumonic  consolidation 
and  complete  pleural  effusion  is  almost  impossible  with  x-ray. 

CHRONIC  THICKENING  OF  PLEURA 

Diffuse  haziness  of  a  part  of  one  side  of  chest  or  lessened  radia- 
bility.     Diaphragmatic  excursion  normal. 

INTERLOBULAR  PLEURISY 

Simply  an  encysted  pleurisy,  wedge  shape,  base  outward  and  the 
pleura  above  and  below  thickened. 

(Pulmonary  abscess  begins  at  hilus  and  extends  out  and  rarely 
reaches  pleura.) 

HYDRO-PNEUMOTHORAX    AND    PYO-PNEUMOTHORAX 

1.  Dark  shadows  in  chest,  diaphragm  lost 

2.  Changes  with  position  of  patient 


26       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

3.  Upper  border  very  clear 

4.  Level  of  fluid  seen  on  shaking  patient  (waves) 

5.  Very  great  increase  of  radiability  above  the  shadow 
Pneumothorax   causes   a   striking  appearance   on   the   screen    or 

plate  if  the  pleural  sac  has  been  free  from  adhesions  so  that  the  lung 
is  free  to  retract  when  the  negative  pressure  is  relieved.  The  en- 
tire half  of  the  thorax  may  appear  as  though  the  lung  had  been 
removed.  Close  examination,  however,  will  show  a  retracted  lung 
lying  against  the  mediastinal  shadow. 

Many  mistakes  are  made  in  the  diagnosis  of  conditions  within  the 
pleural  cavity.  It  is  sometimes  very  difficult  or  even  impossible  to 
differentiate  between  an  opaque  fluid  in  the  pleural  cavity  and  an 
unresolved  pneumonia  involving  the  entire  lung.  This  condition 
is  by  no  means  rare  and  will  sometimes  require  the  use  of  the  as- 
pirating needle  in  order  to  clear  up  the  diagnosis. 

Pulmonary  abscesses  seldom  extend  to  the  periphery  of  the  lung 
and  require  very  careful  localization.  It  is  very  unwise  to  examine 
a  patient  for  the  determination  of  the  presence  of  a  pulmonary  ab- 
scess after  coughing  and  expectorating  pus.  It  is  much  better  to 
wait  and  give  the  abscess  cavity  a  chance  to  become  filled  with  pus, 
at  least  partially,  and  then  examine  in  the  erect  posture  or  semi-re- 
cumbent. Areas  of  lung  suppuration  without  cavities  resemble  por- 
tions of  pus  drowned  lung,  such  as  are  seen  after  the  blocking  of  a 
bronchus  by  a  foreign  body  has  continued  for  a  long  period  of  time. 

In  all  examinations  of  the  chest  by  means  of  the  x-ray,  it  is  well 
to  remember  that  you  are  differentiating  various  physical  conditions 
of  the  lungs  and  endeavoring  to  interpret  these  in  terms  of  patho- 
logical entities.  Very  frequently  the  interpretation  cannot  be  made 
accurately,  and  no  attempt  should  be  made  to  so  interpret  the  find- 
ings without  careful  correlation  with  the  other  clinical  findings,  such 
as  history,  etc. 

If  one  has  had  considerable  experience  in  examination  of  disease 
of  the  thorax,  he  is  inclined  to  thoroughly  scrutinize  the  region  of 
the  diaphragm  in  every  instance  and  to  carefully  observe  the  degree 
of  visibility  and  the  form  and  the  excursion  of  the  diaphragm. 

Pulmonary  tuberculosis  is  diagnosed  by  the  x-ray  only  in  so  far 
as  we  care  to  interpret  certain  physical  conditions,  which  are  thus 
beautifully  shown  as  tuberculous  and  assume  that  these  conditions 
are  always  caused  by  the  bacillus  of  Koch. 

Personally  I  would  hesitate  to  make  a  diagnosis  of  pulmonary 
tuberculosis  in  any  but  the  most  advanced  stages  by  means  of  the 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      27 

Roentgen  ray  findings  alone.  Taken  in  conjunction,  however,  with 
the  physical  signs,  temperature  and  weight  record  and  history, 
trivial  x-ray  findings  may,  when  so  associated,  acquire  great  signifi- 
cance and  enable  the  all  important  early  diagnosis  of  tuberculous 
infection  in  many  patients  to  become  an  accomplished  fact. 

It,  of  course,  is  ridiculous  to  state  that  we  do  not  see  the  tuber- 
cular bacilli  with  the  x-ray.  Neither  do  I  believe  that  we  see  a 
peculiarly-shaped  habitation  of  the  bacilli  as  one  might  expect  to  see 
musk  rat  homes,  nor  do  I  believe  that  there  is  any  strictly  pathogno- 
monic pulmonary  change  attributable  solely  to  the  tubercle  bacilli 
with  one  hundred  per  cent,  of  accuracy,  but  the  fact  remains  that 
there  are  several  rather  characteristic  pulmonary  changes  which  we 
have  learned  by  experience  to  expect  to  see  in  patients  suffering 
from  tuberculosis  and  have  come  to  attribute  these  changes  to  the 
pathology  of  the  disease. 

The  earliest  of  these  changes  is  the  so-called  fan,  so  well  de- 
scribed by  Dunham,  best  seen  in  thin  chests  and  early  cases.  This 
should  only  be  studied  in  excellent  stereoscopic  plates. 

Dunham  says,  "the  characteristic  tuberculosis  plate  marking  con- 
sists of  a  fan-shaped  density  with  the  base  of  the  triangle  toward 
and  near  the  pleura,  the  apex  toward  the  hilum  and  connected  to  the 
hilum  with  a  heavy  trunk.  The  pathological  lesion  within  the  lung 
which  causes  the  fan-shaped  density  is  a  cone  that  has  its  base  to 
the  pleura  and  its  apex  toward  the  hilum.  The  density  within  this 
fan-like  area  varies  greatly.  The  radiating  linear  markings  may 
either  be  interwoven  and  broadened,  studded,  obscured  by  a  filmy 
cloud  effect,  mottled,  matted  together  or  entirely  blotted  out.  One 
of  the  most  striking  characteristics  of  the  tuberculosis  picture  is  the 
varying  degree  of  change  in  the  different  trunk  groups  in  contrast 
to  the  general  homogeneous  change  in  diseases  which  might  simulate 
tuberculosis,  also  the  lack  of  continuity  with  which  the  trunks  may 
be  involved.  Thus  we  may  have  the  vetebral  and  second  interspace 
trunks  on  the  right  side  involved  and  only  the  first  interspace  trunk 
on  the  left  side.  Further,  it  is  very  striking  to  note  the  constancy 
with  which  early  or  slight  lesions  in  the  adult  are  limited  to  the 
trunks  of  the  lower  lobes. 

"If  the  fine  linear  markings  of  a  given  trunk  are  fuzzy  or  are 
faintly  obscured  by  a  cloud  effect  and  the  fan  appears  to  be  wide 
open,  active  tuberculosis  is  suggested  On  the  other  hand,  if  the 
linear  markings  beyond  the  trunk  and  the  fan  are  partially  closed,  a 
healed  lesion   is   suggested.     This  condition  is  emphasized  if  it  is 


28       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

accompanied  with  heavy,  coarse  interweavings  which  reach  to  or 
near  the  periphery.  The  heavy  trunks  between  such  areas  and  the 
hilum  are  usually  broad  and  dense." 

Practically  this  fan-shaped  appearance  is  that  which  would  be 
caused  by  any  low  grade  inflammatory  process  which  has  spread 
by  continuity  of  mucosa. 

In  advanced  instances  of  the  disease  you  see : 

1.  Dunham's   fans 

2.  Lung  suppuration 

3.  Tuberculous  adenopathy 

4.  Thickened  pleura 

5.  Formation  of  cavities 

6.  Local  pneumonias 

The  degree  of  activity  of  a  tuberculous  lung  lesion  is  inversely 
proportional  to  the  distinctness  of  outline  or  limiting  border.  If 
outline  is  sharp,  disease  is  quiescent;  but  if  it  shades  off  into  outly- 
ing tissue,  it  is  active. 

The  above  cannot  be  seen  on  the  screen,  but  you  should  use  low 
unit  radiation  for  fluoroscopy  and  should  make  stereoscopic  pictures 
for  final  detail. 

1.  Patient  should  not  breathe  (Diaphragm  is  indicator,  if  vis- 

ible) 

2.  Patient  must  not  move 

3.  If    active    tuberculous    area    will    be    smoky,    foggy,    hazy, 

blurred,  indistinct 
If  disease  is  quiescent  plates  will  show 

1.  Sharp  demarcation 

2.  Sharp  contrast 

3.  Dense  small  shadows 

4.  Xo  fog,  smoke  or  haze 

5.  Dense  shadows  of  regular  outline  and  sharp  demarcation 

denote  healed  process 

DIFFERENTIAL  DIAGNOSIS 

Localized  long  suppuration  resembles  alveolar  tuberculosis,  but 

1.  It  is  confined  to  one  or  more  areas 

2.  Fan-shaped  area  larger 

3.  Does  not  extend  to  periphery  of  lung 

4.  Whole  process  denser 

5.  Patients  are  very  sick 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      29 

IIILUS   TUBERCULOSIS 

1.  Is  a  disease  of  childhood 

2.  Is    a    peribronchial    tuberculo-adenopathy 

Glands  break  down,  liquefy  and  break  through  into  a  bronchus 
and  by  extension  now  becomes  an  alveolar  tuberculosis.  It  may 
never  go  on  to  above  extent  and  rarely  does.  If  outline  be  indis- 
tinct and  blurred,  process  is  active.  If  dense  clear  cut  outline,  gland 
is  probably  calcified,  healed  and  quiescent. 

WARNING 

Any  infectious  disease  of  childhood  or  bronchial  irritation  of 
inflammation  will  enlarge  the  peribronchial  glands,  but  these  will 
usually  promptly  clear  up  as  convalescence  progresses. 

FOREIGN  BODIES  IN  RESPIRATORY  PASSAGES 

Nature — Anything  small  enough  to  get  in  by  inspiration. 
Location — From    nose    downward    (never    be    satisfied    with 

screen  examination  solely). 
Favorite  location  is  behind  the  heart  shadow;  more  go  down 
right  bronchus. 
Always  make  lateral  and  two  antero-posterior  views  to  locate  a 
foreign  body  which  is  transparent  to  x-ray. 

1.  History 

2.  Area  of  atelectasis  or  lung  suppuration  with  foreign  body 

at  handle  of  fan 

3.  Two  antero-posterior  views  should  be  made — one  with  ster- 

num on  plate,  one  with  back  on  plate 

If  small  enough  to  go  through  the  larynx  it  may  be  found  in  the 
trachea,  bronchus  or  lung.  The  foreign  body  may  be  expected  to 
gravitate  downward  until  it  reaches  a  bronchus  whose  size  prevents 
admission. 

The  foreign  body  may  be  opaque  or  transparent  to  the  x-ray,  but 
it  requires  localization  irrespective  of  this  fact.  On  several  occa- 
sions a  foreign  body  supposed  to  be  in  the  lung  has  been  found  in  the 
nose  and  on  many  occasions  in  the  bowel.  The  screen  is  not  of 
much  avail  in  this  particular  instance,  and  it  is  much  more  satisfac- 
tory to  make  very  rapid  plates  of  the  chest,  making  two  antero-pos- 
terior and  one  lateral. 

If  a  foreign  body  is  transparent  to  x-ray,  it  may  reasonably  be 
expected  to  cause  irritation  at  its  seat  with  some  resulting  inflamma- 


30       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

tion  and  possible  blocking  of  the  bronchus,  resulting  in  atelectasis, 
and  later  localized  suppuration. 

My  associate,  Dr.  Grier,  has  published  in  the  American  Journal 
of  Roentgenology,  the  results  of  our  experience  in  the  examination 
of  very  many  instances  of  foreign  bodies  of  various  types  in  the  air 
passages.  It  is,  therefore,  unnecessary  for  me  to  add  anything  to 
what  he  has  said.  ("Roentgen  Examination  of  Foreign  Bodies." 
G.  W.  Grier,  M.D.) 

THE    HEART 

Roentgen  examinations  of  the  heart  are  performed  for  the  pur- 
pose of  obtaining  the  following  data : 

Size,  shape,  position,  condition  of  aorta,  presence  or  absence  of 
pericarditis. 

Size — It  seems  to  me  that  clinicians  should  be  interested  in  this 
if  only  to  determine  whether  or  not  a  heart  is  of  sufficient  size  to 
take  care  of  the  circulatory  requirements  of  the  individual  under 
examination  without  being  expected  to  unduly  exert  itself.  This 
is  simply  a  problem  in  hydraulics,  and  I  am  quite  certain  that  any 
observer  will,  in  a  short  time,  have  his  attention  called  to  this  fact. 

On  making  a  rapid  fluoroscopic  observation  of  a  heart,  having 
previously  examined  the  individual  and  taken  his  blood  pressure, 
the  observer  should  be  able  to  state  whether  or  not,  in  his  judgment, 
any  given  heart  is  sufficiently  large  for  its  work.  If  the  heart  is 
over  size,  it  is  from  dilatation  or  hypertrophy.  If  it  be  hypertro- 
phied  its  behavior,  its  muscular  action,  its  excursion,  its  apical  re- 
traction will  immediately  proclaim  it  such.  Similarly,  if  it  be 
dilated,  the  very  lack  of  the  foregoing  characteristic  muscular  activ- 
ity will  inform  the  observer  of  that  fact.  A  dilated  heart  gives  the 
impression  of  a  heart  in  chronic  diastole.  When  a  healthy  heart, 
whether  hypertrophied  or  not  contracts  the  apex  tracts.  The 
activity  of  the  heart  is  determined  by  the  retraction  of  the  apex,  the 
diminution  in  size  or  change  in  area,  and  change  in  position  of  the 
heart  due  to  its  systolic  rotation  on  the  great  vessels  on  which  it  is 
suspended,  in  conjunction  with  the  rate  of  contraction  and  expansion. 

The  only  way  to  learn  anything  about  this  particular  branch  of 
medicine  is  to  carefully  and  intelligently  examine  the  heart  by  every 
method  available,  then  study  the  same  heart  with  the  screen  and  in 
this  way  acquire  the  ability  to  interpret  for  yourself  the  visualiza- 
tion of  the  heart  in  action  so  beautifully  seen  upon  the  screen. 

The  shape  of  the  heart  varies  greatly.     You   will  soon  be  able 


THE  AMERICAN  CONGRESS  OX  INTERNAL  MEDICINE      31 

to  divide  them  into  transverse,  vertical,  globular,  drop  and  com- 
pressed. 

Drop  heart  has  no  pathological  signification.  It  is  usually  small 
and  occurs  in  patients  having  long  trunks  and  general  visceroptosis. 

The  transverse  heart  on  the  other  hand  indicates  a  distinctly 
dangerous  cardiac  condition.  It  is  observed  most  frequently  in 
those  men  whose  abdomen  exceeds  in  circumference  their  chest, 
who  are  what  are  commonly  known  as  "stomach  athletes."  These 
are  the  types  recorded  in  the  daily  print  as  dying  of  acute  indiges- 
tion or  cardiac  failure  immediately  subsequent  to  an  elaborate 
banquet. 

A  displacement  of  the  heart  is,  of  course,  immediately  observed; 
pleurisy  with  effusion,  particularly  right-sided  pleurisy  may  cause 
considerable  displacement. 

The  congenital  dextracardia  is  always  worthy  of  comment,  but 
the  marked  cardiac  displacements  are  those  observed  as  a  result  of 
rearrangement  of  the  thoracic  contents  due  to  old  chronic  fibroid 
phthisis. 

Pericarditis  with  effusion  is  very  frequently  overlooked  and 
very  often  diagnosed  as  a  simple  Cardiac  hypertrophy.  It  is  well 
to  remember  that  the  re-entrant  angle,  which  is  found  by  percus- 
sion and  which  is  found  to  have  disappeared  upon  percussion  in 
this  condition  has  not  actually  disappeared  but  is  rather  accentuated 
when  the  heart  is  examined  upon  the  screen.  This  confusion  is 
bound  to  cause  mistakes.  The  diagnosis  of  pericarditis  with  effu- 
sions is  rather  better  made  by  the  fact  that  a  portion  of  the  heart 
shadow,  its  auricular  shadows  and  shadows  of  the  great  vessels 
at  the  root  of  the  heart,  is  almost  lost,  due  to  the  distension  of  the 
pericardium  with  fluid.  Moreover  the  cardiac  activity  is  very 
greatly  reduced,  apparently  the  apical  retreat  being  no  longer 
noticeable. 

The  various  changes  in  contour  of  the  heart  consequent  to 
valvular  insufficiency  would  require  an  afternoon  for  their  dis- 
cussion. Moreover  they  have  been  already  beautifully  described 
in  Roentgen  literature.  They  will,  therefore,  not  be  further  con- 
sidered. 

The  aorta  is  best  inspected  by  means  of  the  screen  and  consid- 
erably more  attention  should  be  paid  to  determination  of  aortitis 
than  has  been  done  in  the  past.  The  writer  claims  that  an  early 
determination  of  aortitis  with  proper  treatment,  thereof,  would 
result  in  an  increasing  rarity  of  aneurysm. 


32      THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Any  deviation  in  size  or  shape  of  the  aorta  requires  explanation 
but  it  does  not  necessarily  mean  aneurysm. 

The  size,  shape  and  position  of  the  arch  is  best  studied  before 
the  screen  and  no  diagnosis  of  aneurysm  should  ever  be  made  until 
the  superior  portion  of  the  arch  has  been  studied  in  the  lateral 
position. 

Syphilitic  aortitis  may  be  frequently  diagnosed  upon  the  screen 
by  marked  increase  in  the  density  of  the  descending  aorta. 

Expansile  pulsation  of  aneurysm  means  an  impulse  synchronous 
with  the  heart  beat.  It  must  be  remembered  that  transmitted  im- 
pulse is  imparted  to  any  tumor  in  the  mediastinum  which  may  be 
in  contact  with  the  aorta.  The  following  table  may  also  note  the 
differences  between  tumors  of  the  mediastinum  and  aneurysm. 

ANEURYSM 

Regular  outline,  spherical 

Pulsatile  and  expansile 

Painful  when  producing  pressure 

Atrophy  of  bone 

Bruit  marked 

Density  high 

Cardiac  dyspnea 

Cardiac  hypertrophy 

Cough  brassy 

Shadow  continuous  with  aorta 

Density  high 

TUMORS 

Outline  irregular  or  spherical 

No  bruit 

No  cardiac  hypertrophy 

No  cardiac  dyspnea 

Often  metastatic 

Rapid  onset 

Irregular   density 

Aorta  can  be  differentiated  sometimes  from  tumor 

Density  may  be  low 
No  mention  has  been  made  of  mediastinal  abscess,  the  result  of 
caries  of  the  cervical  or  dorsal  spine,  and  when  such  a  diagnosis 
is  made  it  is  usually  an  accident. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      33 

The  writer  realizes  thai  many  books  could  be  written  on  the 
subjects  touched  upon  and  the  idea  of  this  paper  is  simply  to  re- 
awaken the  internist  to  the  value  of  the  lluoroscope  and  plate  in 
the  examination  of  the  chest  as  a  means  of  stimulating  his  acuity 
in  other  methods  of  physical  examinations  as  well  as  the  advantage 
of  having  all  the  possible  evidence  in  any  given  case. 

No  roentgenologist  can  make  successful  studies  of  the  chest 
unless  he  be  enough  of  an  internist  to  appreciate  all  the  various 
forms  of  pathology  which  one  may  expect  to  find  therein. 

Xo  roentgenologist  can  make  successful  studies  of  the  chest 
in  having  been  associated  with  many  excellent  internists,  men  well 
informed  as  to  gross  pathology,  symptomatology,  etc.  Anything  that 
he  knows  along  this  line  is  due  to  his  past  association  with  such 
men  as  C.  Q.  Jackson,  Litchfield,  McKelvy,  Lichty,  Alexander, 
Jones.  Mercur,  Klotz,  MacLachlan  and  many  others. 


A  RESUME  OF  THE  ROENTGEN  FINDINGS  IN  ABDOM- 
INAL PATHOLOGY 

By  WILLIAM  A.  EVANS 
Detroit,  Mich. 

Your  president,  in  his  address  last  year,  paid  tribute  to  the  sci- 
ence of  roentgenology  in  this  fashion  "To  it  internal  medicine 
owes  much,  not  only  in  indicating  new  avenues  of  progress,  but 
as  well  in  scientific  demonstration  of  the  verity  of  what  empirically 
we  have  established  as  facts  in  internal  medicine,  and  we  have 
made  but  a  beginning."  But  many  roentgenologists  have  become 
so  enthusiastic  over  their  method  of  examination  they  have  for- 
gotten the  ordinary  clinical  methods  and  even  gone  so  far  as  to 
hold  in  disdain  the  work  of  the  clinician.  There  is  certainly  no 
basis  for  such  self-glorification,  for  sober  consideration  of  our 
results  must  convince  us  that  our  conclusions  are  drawn  falsely. 

It  is  in  this  spirit  of  humility  that  I  address  this  meeting.  I 
hope  to  present  some  of  our  problems  and,  at  the  same  time,  to  in- 
dicate how  you,  as  internists,  can  help  advance  our  specialty  and 
thus  advance  medicine  generally.  But  my  humility  must  not 
prevent  my  giving  expression  to  thoughts  which  came  to  me  during 
my  recent  review  of  the  late  literature  on  differential  diagnosis  of 
abdominal   conditions.      In   one   of   the   volumes   of   "monographic 


34       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

medicine"  published  in  1916,  the  author  dismisses  the  subject  of 
roentgenology  of  the  gall  bladder  with  these  words:  "An  x-ray 
made  by  an  expert  will  sometimes  show  the  shadow  of  a  gallstone." 
Roentgen  aid  in  gastric  cancer  receives  the  consideration,  "Exam- 
ination by  x-rays  shows  an  interference  of  peristalsis  and  some- 
times notching  of  the  stomach  wall;"  and  in  the  differential  diag- 
nosis of  chronc  appendicitis,  no  reference  whatever  is  made  to  the 
roentgen  ray.  Apparently  this  writer  has  not  had  the  advantage 
of  association  with,  and  the  co-operation  of  a  competent  roentgen- 
ologist, and  neither  has  he  followed  roentgen  literature,  for  other- 
wise the  work  of  George,  Case,  Carmen,  Crane  and  many  others 
must  have  shown  him  the  merits  of  roentgenological  study  of  ab- 
dominal pathology.  I  trust  the  time  will  soon  come  when  an  author 
will  not  have  the  temerity  to  disregard  so  thoroughly  and  com- 
pletely such  a  valuable  aid  in  differential  diagnosis  as  the  roentgen 
method  has  proven  itself  to  be. 

It  will  not  be  possible  for  me  to  take  up  in  detail  any  organ  or 
group  of  organs.  I  will  rather  have  to  be  content  with  suggesting 
the  possibilities  and  problems  in  the  demonstration  of  lesions  of 
the  several  abdominal  structures.  Before  taking  up  the  individual 
headings,  it  should  be  understood  that  the  roentgen  study  is  car- 
ried out,  in  the  first  place,  by  both  the  fluoroscopic  and  the  roentgen- 
ographic  methods.  Both  methods  have  their  indications  and  merits, 
but  one  cannot  be  used  to  the  exclusion  of  the  other.  It  should 
also  be  understood  that  the  examinations  are  made  both  in  the 
upright  and  horizontal  positions,  and  that  suitable  considerations 
have  been  paid  to  the  preparation  of  the  patient. 

Diaphragm.  In  the  study  of  the  diaphragm,  the  fluoroscopic 
method  is  the  most  useful  and  the  erect  position  is  preferable  for 
such  study.  The  first  thing  to  be  noted  is  the  contour  and  relative 
height  of  the  diaphragm  lines,  and  then  the  contour,  in  detail,  of 
each  diaphragm.  The  height  of  the  diaphragm  lines  is  varied  by 
abdominal  conditions,  such  as  enlarged  liver,  enlarged  magenblase, 
distended  splenic  flexure,  subphrenic  abscess,  or,  in  fact,  any  large 
abdominal  tumor,  or  even  effusion.  When  the  diaphragm  on  either 
side  shows  waves  or  undulations,  one  can  strongly  suspect  either 
abdominal  or  chest  pathology.  The  structure  of  the  diaphragm  and 
its  enervation  renders  certain  fibres  subject  to  irritation  from 
abdominal  organs,  and  it  is  the  reflex  irritation  from  abdominal 
lesions  which  produces  the  irregular  contraction  of  the  diaphragm 
muscles  and,  as  a  result,  the  mammillations.     This  condition  has 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      35 

been  especially  noted  in  gastric  ulcer.  The  plate  method  of  exam- 
ination is  of  particular  value  in  determining  the  presence  of  a 
subphrenic  abscess.  In  this  case,  it  is  customary  to  look  for  a 
bubble  of  gas,  this  appearing  between  the  pus  level  and  the  dia- 
phragm, the  presence  of  air  permitting  the  pus  to  assume  a  straight 
line,  and  this  rinding  may  be  overlooked  in  the  fluoroscopic  observa- 
tion. Usually  the  condition  of  the  patient  does  not  permit  the 
erect  posture  for  but  a  brief  period,  and  this,  in  itself,  would  force 
the  using  of  plates. 

Pancreas.  The  study  of  the  pancreas  is  rendered  difficult  both 
by  its  structure  and  its  relations.  Well-developed  cysts  of  the  head 
of  the  pancreas  have  been  recognized  during  a  roentgen  examina- 
tion, by  the  fact  that  there  has  been  a  displacement  and  change  in 
the  relations  of  the  pylorus  and  duodenum.  Carcinoma  of  the  pan- 
creas has  also  been  diagnosed  by  the  disturbance  in  outline  and 
relations  of  the  duodenum  produced  by  the  presence  of  a  new 
growth. 

A  careful  search  of  the  literature  failed  to  reveal  a  report  where 
pancreatic  calculus  had  been  demonstrated  by  the  roentgen  method 
of  examination,  but  there  is  no  reason  why  these  should  not  be 
demonstrated,  and  no  doubt  the  shadows  have  been  overlooked  or 
confused  with  gallstones  or  other  abnormal  shadows.  In  this  in- 
stance, it  would  seem  that  with  the  co-operation  of  the  itnernists, 
cases  showing  pancreatic  disease  should  be  referred  to  the  roentgen- 
ologist for  a  careful  study  of  the  pancreatic  region  for  calculus. 

Liver.  The  indications  for  roentgenologic  hepatic  study  are 
limited.  An  enlarged  liver  is  demonstrated  at  times  on  account  of 
the  distortion  of  the  diaphragm  line  or  from  the  displacement  of 
the  abdominal  contents.  In  our  service,  we  were  able  to  demon- 
strate that  a  large  tumor  in  the  upper  right  quadrant  was  probably 
a  cyst  of  the  liver,  this  being  verified  by  operation. 

Gall  Bladder.  For  some  years,  the  study  of  the  gall  bladder  by 
the  roentgen  examination  was  confined  simply  to  the  demonstra- 
tion of  calculi  and  adhesions.  Until  recently,  no  routine  examina- 
tion of  the  gall  bladder  region  was  made,  the  question  of  adhesions 
being  determined  during  the  study  of  the  duodenum.  It  has  been 
the  custom  for  some  time  to  describe  the  so-called  gall  bladder 
position  of  the  duodenum,  in  its  relation  to  the  pylorus,  and  also 
to  explain  certain  deformities  of  the  duodenum  by  periduodenal 
adhesions  complicating  a  cholecystitis.  When  the  duodenum  was 
held   toward    the    median    line,   and    somewhat   upward,    when    the 


36       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

pylorus  extended  a  little  far  to  the  right,  when  the  mobility  of  the 
duodenum  was  reduced,  and  when  there  was  tenderness  associated 
with  manipulation  of  the  duodenum,  we  have  assumed  that  there 
was  gall  bladder  disease  from  the  demonstration  of  an  occasional 
gallstone,  and  these  rather  accidentally,  we  have  advanced  to  the 
position  where  some  roentgenologists  report  the  demonstration  of 
at  least  fifty  per  cent,  of  gall  bladder  deposits.  One  worker  has 
stated  that  his  percentage  is  eighty  per  cent.,  but  he  published  no 
figures  to  support  his  statement.  However,  in  our  reports,  we 
always  call  attention  to  the  fact  that  negative  evidence  of  gall- 
stones simply  indicates  that  no  stones  are  present  which  have  a 
lime  content  of  two  and  a  half  per  cent,  or  more. 

But  what  is  probably  more  important  than  the  demonstration 
of  gallstones  is  the  demonstration  of  the  gall  bladder  itself.  While, 
as  far  as  we  know,  we  have  never  been  able  to  demonstrate  a  nor- 
mal gall  bladder,  we  are  certainly  finding  on  properly  exposed  plates 
outlines  which  have  been  proven  to  be  cast  by  a  pathologic  gall 
bladder.  The  conditions  demonstrated  have  included  hydrops  of 
the  gall  bladder,  empyema  of  the  gall  bladder,  and  chronic  thick- 
ening of  the  gall  bladder  wall.  Inasmuch  as  the  normal  gall  blad- 
der is  at  least  very  seldom  demonstrated,  we  can  safely  assume  that 
the  shadow  of  the  gall  bladder  definitely  indicates  pathology. 

Spleen.  The  differential  diagnosis  of  tumors  in  the  upper  left 
quadrant  can  be  aided  by  the  demonstration  of  the  splenic  outline. 
In  order  to  show  this  organ,  it  is  necessary  to  distend  the  stomach 
with  gas,  and  also  to  have  considerable  liquid  in  the  stomach.  With 
the  patient  on  the  right  side,  with  the  above  conditions  complied 
with,  the  splenic  outline  is  frequently  very  well  shown. 

Peritoneum  and  Mesentery.  The  roentgen  method  of  examina- 
tion is  frequently  useful  in  the  differential  diagnosis  of  extravisceral 
new  growths.  The  usual  findings  are  those  of  a  displacement  of 
the  stomach,  small  intestine,  or  colon,  these,  of  course,  being  studied 
best  by  being  outlined  with  the  usual  opaque  salt.  We  have  been  able 
to  diagnose  differentially  a  low  abdominal  mass  as  a  dermoid  cyst, 
since  we  identified  shadows  in  the  tumor  region  which  were  those 
of  teeth.  The  very  important  subject  of  adhesions  in  the  abdominal 
cavity,  of  course,  is  best  studied  by  this  method  of  examination, 
fluoroscopy  alone  being  the  most  satisfactory  procedure,  inasmuch 
as  this  permits  of  palpation  and  the  demonstration  of  pain  points. 
The  distribution  of  the  barium  in  tubercular  peritonitis  is  char- 
acteristic,  there   being   filling   and    distention    of    certain   loops    of 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      37 

the  small  bowel  with  barium,  and  distention  of  other  loops  with 
gas. 

Urinary  Tract.  The  question  of  the  roentgen  diagnosis  of  urinary 
calculi  is  so  well  known  that  the  matter  will  be  given  little  consider- 
ation here.  In  these  cases,  the  value  of  the  roentgen  examination 
is  not  in  the  diagnosis  of  a  calettlus,  but  more  to  serve  as  a  guide 
in  treatment  ami  a  guide  in  prognosis.  By  no  other  method  of  exam- 
ination can  the  size,  shape  and  number  of  stones  be  learned. 

The  question  of  referred  pain  in  renal  calculus  should  be  men- 
tioned at  this  time.  In  our  service,  I  recall  four  cases  in  which 
the  symptoms  were  all  on  one  side,  and  the  examination  revealed 
a  shadow  of  calculus  on  the  opposite  side.  This  does  not  neces- 
sarily mean  that  the  pathology  was  entirely  one-sided,  but  it  does 
mean  that  there  can  be  a  bilateral  pathology  with  just  unilateral 
symptoms. 

New  growths  and  disease  other  than  calculus  can  be  well  studied, 
provided  the  proper  technic  has  been  carried  out  in  obtaining  plates 
of  the  kidney  regions.  In  the  rare  exceptions  that  the  plates  do 
not  show  the  kidney  outline,  one  can  usually  suggest  the  presence 
of  a  perinephric  abscess.  In  this  condition,  there  is  usually  a  uni- 
form density  from  the  crest  of  the  ilium  on  the  affected  side  to 
the  last  rib.  In  every  other  case,  it  is  possible  to  obtain  a  kidney 
outline,  and  unless  the  plates  obtained  show  this,  further  exposures 
should  be  made. 

The  invaluable  aid  rendered  by  the  study  of  the  filled  bladder, 
ureters  and  the  pelves  of  the  kidneys  with  an  opaque  solution  is  well 
known,  and  nothing  new  has  been  recently  brought  out  along  this 
line. 

t  In  connection  with  bladder  symptoms,  by  making  posteroanterior 
plates  as  well  as  anteroposterior,  we  have  been  able  to  demonstrate 
the  shadow  of  the  prostate,  both  that  of  a  chronic  prostatitis  and  a 
prostate  modified  by  a  new  growth. 

A  relatively  large  number  of  cases  are  referred  to  the  roentgen- 
ologist for  examination  of  the  urinary  tract  with  simply  the  history 
of  frequent  urination,  pain  on  urination  and  lumbar  or  inguinal 
pain.  Four  years  ago,  in  reviewing  a  large  number  of  plates  made 
of  cases  referred  for  suspected  calculus,  I  was  struck  with  the  large 
number  of  spine  lesions  which  could  be  detected  on  the  plates  made 
of  the  midureter  region.  It  occurred  to  me  that  possibly  there  was  a 
distinct  connection  between  the  spinal  lesions  and  the  symptoms  of 
urinary  calculus,  and  a  paper  was  written  for  the  American  Roent- 


38       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

gen  Ray  Society  under  the  title  "The  Syndrome  of  Urinary  Cal- 
culus Caused  by  Spinal  Lesions."  Since  that  time,  when  the  exam- 
ination for  stone  is  negative,  we  feel  it  our  duty  to  make  a  detailed 
study  of  the  lower  spine  and  to  report  any  changes  found.  It  has 
been  clearly  and  definitely  demonstrated  that  bone  lesions  of  the 
lumbar  and  lumbosacral  regions  frequently  manifest  themselves 
in  disturbances  in  kidney  function,  micturition  and  lumbar  and 
inguinal  pain. 

The  variety  of  lesions  producing  these  symptoms  is  great.  Simple 
displacements  or  rotations,  inflammatory  processes  involving  the 
articular  facets  and  anomalous  development  of  the  fifth  lumbar 
body  or  faulty  development  of  the  first  sacral  segment  have  all 
been  found  in  these  cases.  Of  course,  any  pathology  in  the  spine 
which  would  cause  an  inflammatory  reaction  in  the  soft  tissues  could 
be  a  factor  in  reflex  irritation. 

Gastrointestinal  Tract.  Before  taking  up  the  detailed  pathology 
of  the  gastrointestinal  tract,  the  question  of  a  method  of  examina- 
tion should  receive  careful  consideration.  There  are  at  present 
two  distinct  methods  of  examination,  one  the  so-called  single  meal, 
and  the  other  the  so-called  double  opaque  meal.  Personally,  I  think 
this  is  a  very  vital  matter,  and  one  that  should  receive  the  earnest 
consideration  of  gastroenterologists,  for  until  there  is  a  standard 
technic  for  the  examination  of  the  intestinal  canal  by  the  opaque 
meal,  there  will  be  difficulty  in  correlating  the  results  of  the  work 
of  different  laboratories.  Personally,  I  can  see  no  objection  what- 
ever to  the  single  meal,  and  believe  it  is  the  proper  method  of  pro- 
cedure. There  is  a  distinct  disadvantage  in  the  double  meal,  in  that 
it  is  reasonable  to  suppose  that  a  large  dose  of  salt  such  as  barium 
or  bismuth  is  bound  to  affect  the  reflexes  of  the  intestinal  canal. 
In  at  least  ninety  per  cent,  of  patients  who  are  examined  in  our 
laboratory  for  gastrointestinal  conditions,  we  find  that  on  the  day 
following  the  administration  of  the  barium  salt,  the  patients  seem 
to  be  markedly  or  even  entirely  relieved  of  their  symptoms,  this 
improvement  usually  continuing  for  several  days.  In  fact,  we  hear 
frequently  that  patients  having  had  the  barium  study  do  not  return 
to  their  physician,  inasmuch  as  they  have  been  entirely  relieved 
of  their  symptoms. 

To  be  more  definite,  a  case  was  referred  a  few  days  ago  for  a 
gastrointestinal  study,  with  the  tentative  diagnosis  of  gastric  ulcer. 
The  first  examination  revealed  a  distinct  pylorospasm,  with  delayed 
emptying.     The   following  day,  a  second  opaque  meal  was  given. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      39 

There  was  an  entire  absence  of  spasm,  and  a  well  formed  duodenal 
cap,  and  an  even  and  normal  escape  of  the  gastric  contents.  The 
condition  in  this  case  was  not  one  of  gastric  ulcer,  but  was  one  of 
gastritis  secondary  to  a  septic  condition  of  the  mouth. 

The  argument  may  be  advanced  that  even  a  single  meal  inter- 
feres with  the  normal  function,  and  we  presume  that  there  is  pos- 
sibly some  truth  in  this  claim,  and  in  many  cases,  the  roentgenologist 
does  take  into  consideration  the  action  of  a  large  amount  of  barium 
in  the  intestinal  tract. 

The  objection  to  the  single  meal  by  the  advocates  of  the  two- 
meal  method  is  that  the  condition  of  the  terminal  ileum  is  the  great- 
est factor  in  reflex  gastric  conditions,  and  if  the  examination  is  made 
with  the  terminal  ileum  empty,  many  pathological  conditions  would 
be  overlooked.  Since  in  no  other  way  can  we  be  sure  that  the 
terminal  ileum  contains  food  except  that  the  food  has  an  opaque 
salt  content,  then  it  must  follow  that  the  detailed  study  of  the 
stomach  should  be  made  when  it  is  determined  that  there  is  still 
food  content  in  the  terminal  ileum.  Granting  that  the  contention 
of  the  two-meal  advocates  is  correct,  there  is  still  no  objection  to  the 
single  method  in  my  mind,  inasmuch  as  an  examination  begun 
within  twelve  or  fourteen  hours  of  a  meal  would  still  permit  us 
to  examine  the  stomach  which  would  be  under  the  influence  of  the 
terminal  ileum  content,  for  a  normal  terminal  ileum  can  have  no 
influence  on  the  stomaach,  and  a  disturbed  ileum  will  show  reten- 
tion from  the  evening  meal  by  the  time  of  the  morning  examina- 
tion. This,  of  course,  would  call  for  the  gastric  examinations  to 
be  begun  between  eight  and  nine  in  the  morning.  This  is  one  of 
the  problems  which  can  only  be  settled  by  the  aid  and  co-operation 
of  the  gastroenterologist. 

At  this  point,  I  would  like  to  make  a  distinction  in  the  cases 
referred  from  the  surgeon  for  examination  and  those  coming  from 
the  internist.  From  my  experience,  I  find  that  the  examination 
of  the  gastrointestinal  tract  for  surgeons  is  much  easier  than  in  the 
cases  sent  from  the  internist.  That  is,  with  greater  frequency  do 
we  demonstrate  actual  lesions,  while  in  the  instance  of  cases  re- 
ferred from  the  internist,  it  is  frequently  a  matter  of  disturbed 
function.  Little  diagnostic  skill  is  necessary  in  demonstrating 
hour-glass  contraction  of  the  stomach  or  a  perforating  gastric  ulcer, 
or  a  chronic  duodenal  ulcer,  or  a  large  gastric  carcinoma,  or  any 
other  lesion  with  gross  anatomical  changes.  It  is  these  cases  which 
have  probably  gotten  the  roentgenologist  in  the  habit  of   making 


40       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

a   roentgen   diagnosis,   rather   than   simply   reporting  the    roentgen 
findings. 

Another  factor  in  the  formation  of  the  roentgen  habit  of  making 
diagnoses  is  the  varying  abilities  of  the  men  referring  cases  for 
examination.  The  large  majority  of  the  cases  coming  to  the  office 
have  had  practically  no  scientific  examinations  made,  and  the  phy- 
sicians referring  the  cases  rely  almost  entirely  upon  the  roentgen- 
ologist for  a  diagnosis.  I  have  been  in  the  habit  of  dividing  physi- 
cians into  three  large  classes,  one  class  to  whom  is  almost  entirely 
unknown  the  real  scientific  study  of  a  case,  a  second  class  who 
have  kept  abreast  with  the  various  advances  in  diagnoses,  but 
whose  energies  are  so  dissipated  that  they  are  not  sufficiently 
familiar  with  the  roentgen  findings  reported  to  properly  interpret 
them,  and  then  the  third  and  smaller  class,  who  use  all  the  various 
methods  to  obtain  a  diagnosis  in  a  given  case. 

To  the  first  class,  we  have,  in  the  order  of  things,  to  make  a 
roentgen  diagnosis,  and  in  these  cases  we  feel  that  we  are  entitled 
to  a  history  and  also  some  of  the  other  physical  findings,  and  these 
are  made  in  a  hurried  way  during  the  ordinary  roentgenologic  ex- 
amination. This  is,  of  course,  not  scientific,  but  most  of  you  who 
are  familiar  with  general  practice  will  appreciate  the  conditions 
under  which  this  plan  is  made  necessary. 

To  the  second  class,  we  usually  report  our  findngs,  and  interpret 
them  in  the  light  of  the  patient's  history  and  symptoms. 

To  the  third  class,  we  have  adopted  the  method  of  simply  re- 
porting our  findings,  and  contenting  ourselves  with  making  pos- 
sibly a  few  suggestions.  We  believe  that  this  third  method  is  the 
ideal  one  and  that  the  roentgenologist  should  not  be  called  upon 
to  make  a  definite  diagnosis  unless  he  has  the  privilege  of  going  over 
all  the  results  of  the  other  examinations. 

A  year  ago,  Charles  H.  Mayo,  in  an  address  before  the  American 
Roentgen  Ray  Society,  said  "To  stand  well  with  the  surgeon,  the 
roentgenologist  should  be  specific  in  his  conclusions,  avoid  verbose 
description  of  his  findings,  and  when  unable  to  make  a  diagnosis, 
frankly  report  the  case  as  indeterminate."  This  should,  and  no 
doubt  does,  apply  equally  well  to  the  internist,  and  to  you,  as  in- 
ternists, then,  I  will  state  the  roentgen  findings  of  the  more  common 
pathological  conditions  of  the  gastrointestinal  tract. 

The  matter  of  size,  shape  and  position  of  the  stomach  and  the 
matter  of  the  length  and  relations  of  the  component  portions  of  the 
colon   have   been   demonstrated,   we  think,  to  be  of   little,   if   any, 


THE  AMERICAN  CONGRESS  OX  INTERNAL  MEDICINE      41 

clinical  value.  As  Mills  of  St.  Louis  pointed  out,  the  contour  and 
relations  of  these  organs  simply  conform  to  the  patient's  habitus. 
The  internist  has  not  fully  appreciated  this  condition,  we  believe, 
for  we  are  frequently  called  upon  to  determine  exactly  the  above 
mentioned  points  in  connection  with  the  stomach  and  colon.  The 
futility  of  the  ordinary  abdominal  belt  has  also  been  clearly  demon- 
strated. 

We  can  classify  the  findings  in  gastric  ulcer  under  the  two  gen- 
eral headings  of  direct  and  indirect,  the  direct  being  a  demonstra- 
tion of  a  definite  change  resulting  from  the  ulceration,  and  the 
indirect  the  disturbances  in  function.  The  most  common  direct 
findings  are  (a)  the  bismuth  fleck  representing  the  ulcer  crater,  (b) 
the  Idling  defect  in  the  gastric  outline,  and  (c)  the  organic  deform- 
ities other  than  defects,  such  as  hourglass  contraction.  The  in- 
direct findings  are  (a)  spastic  manifestations,  (b)  abnormalities  in 
peristaltic  waves,  (c)  disturbed  motility,  (d)  unusual  filling  of  the 
duodenum  and  (e)  pressure  pain  points. 

The  very  complete  work  on  gastric  carcinoma  which  was  pub- 
lished by  Dr.  Smithies  was  recently  reviewed,  and  I  am  in  full 
accord  with  all  that  he  has  stated  as  regards  the  value  of  the  roent- 
gen examination  in  gastric  carcinoma.  Still,  in  practice,  it  does 
not  work  out  as  one  would  believe  from  reading  Dr.  Smithies' 
comments.  I  am  sure  that  every  roentgenologist  frequently  is  able 
to  demonstrate  a  gastric  carcinoma  when  the  condition  was  not 
thought  of  clinically,  even  when  the  case  had  been  worked  up  by 
a  competent  internist. 

The  chief,  and  frequently  the  only  finding  in  gastric  carcinoma 
is  a  filling  defect.  Depending  on  the  location,  there  will  be  dis- 
turbances in  motility.  For  instance,  with  a  carcinoma  involving 
the  cardiac  end  of  the  stomach,  there  is  usually  early  emptying. 
In  carcinoma  involving  the  middle  pole,  the  emptying  time  is  fre- 
quently not  disturbed,  and,  of  course,  in  carcinoma  of  the  pylorus, 
there  is  usually  obstruction.  Probably  the  chief  values  of  the 
roentgen  ray  in  gastric  carcinoma  are  the  demonstration  of  the 
exact  location  of  the  lesion,  the  possibilities  of  surgical  intervention, 
and  the  prognostic  value. 

Undoubtedly  the  majority  of  cases  coming  to  the  internist  with 
gastric  complaints  have  conditions  outside  of  the  stomach  which 
produce  the  symptoms.  The  gastric  symptoms  resulting  from  small 
intestinal,  appendiceal  and  colonic  conditions  will  be  considered 
separately  under  the  several  headings. 


42       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

The  interpretation  of  the  findings  of  pylorospasm  and  gastric 
retention  should  not  be  made  without  carefully  considering  the 
question  of  these  findings  being  the  result  of  a  gastric  manifesta- 
tion of  tabes.  Not  infrequently  we  have  suggested  syphilis  as  being 
the  etiologic  factor  in  pylorospasm  and  retention,  and  later  tests 
have  proven  our  suggestion  correct.  The  question  of  organic  de- 
formities of  the  stomach  due  to  syphilis  is  one  of  importance.  Un- 
doubtedly a  large  number  of  cases  presenting  a  tumor  of  the 
stomach  have  been  diagnosed  as  carcinoma,  when  in  reality  they 
were  the  result  of  syphilis.  The  roentgenologist  should  always 
suggest  the  necessity  of  differentiating  between  carcinoma  and 
syphilis  by  the  other  methods  of  examination. 

The  most  constant  and  important  finding  in  duodenal  ulcer  is 
duodenal  deformity.  Following  the  classification  by  Carmen,  of 
the  Mayo  Clinic,  there  are  four  types  of  deformity,  these  depending 
somewhat  on  the  extent  of  the  ulcer  and  on  the  amount  of  scar  tis- 
sue formation.  The  four  types  are  the  pine-tree,  the  niche  type, 
the   incisura,  and  the  small  dense  bulb. 

The  indirect  evidences  of  duodenal  ulcer  are  hypertonus,  hyper- 
peristalsis  and  hypermotility  of  the  stomach,  the  six-hour  residue 
in  chronic  ulcer,  antrum  dilatation  and  gastric  spasm. 

The  question  of  deformity  of  the  duodenum  cannot  always  be 
explained  by  changes  in  the  duodenal  wall,  for  frequently  the  dis- 
turbances in  outline  and  in  filling  is  the  result  of  duodenal  bands. 
The  duodenum  also  is  frequently  influenced  by  reflex  conditions 
from  other  abdominal  conditions. 

The  cause  of  reverse  peristalsis  of  the  duodenum  has  not  been 
definitely  determined.  It  is  claimed  by  some  that  reverse  peristalsis 
is  incident  to  respiration,  but  we  are  sure  that  this  is  not  the  case. 
We  have  not  had  a  sufficient  number  of  observations  of  this  con- 
dition to  determine  its  exact  significance,  if  any. 

Small  Bowel.  In  the  upper  small  bowel,  comparatively  few 
lesions  are  found.  Most  frequently,  the  disturbance  is  the  result 
of  adhesions,  and  this  point  has  been  mentioned  elsewhere  in  this 
paper.  Constrictions  resulting  in  obstruction  have  been  demon- 
strated, and  it  has  been  proved  at  operation  that  an  ulcer  has  been 
the  basis  of  the  pathology.  Another  infrequent  finding  is  diver- 
ticulitis, the  identification  of  which  should  not  be  difficult. 

Normally,  the  opaque  meal  will  have  passed  into  the  colon  at 
twelve  hours.  Any  residue  after  this  time  should,  be  classified 
as  ileal  stasis.     The  importance  of  the  ileal  stasis  as  a  factor  in 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      43 

gastric  symptoms  is  second  only  to  the  appendix.  '  The  causes  of 
ileal  stasis,  as  determined  by  the  roentgen  method  of  examination, 
are  adhesions  and  kinking,  spasm  of  the  ileocecal  sphincter,  and 
incompetency  of  the  ileocecal  valve.  Under  the  head  of  adhesions, 
should,  of  course,  come  the  atypical  mesenteric  bands  known  as 
Jackson's  membrane.  The  question  of  incompetency  of  the  ileo- 
cecal valve  is  most  often  demonstrated  by  means  of  the  opaque 
enema,  but  at  times,  by  frequent  observations  of  a  given  opaque 
meal,  it  can  be  definitely  shown  that  the  cecal  contents  have  been 
regurgitated   into  the   terminal   ileum. 

The  importance  of  the  appendix  in  gastrointestinal  disease  can- 
not be  overstated.  The  roentgen  evidences  of  appendiceal  disease 
are,  for  the  most  part,  direct.  The  most  common  is  retention,  the 
degree  of  retention  usually  determining  the  importance  of  the 
appendix  as  a  factor  in  the  gastrointestinal  symptoms;  (b)  tender- 
ness localized  to  the  appendix;  (c)  kinking  or  angulation  of  the 
appendix,  indicating  that  appendiceal  drainage  would  be  imperfect ; 

(d)  irregular  filling  suggesting  either  concretions  or  constrictions; 

(e)  adhesions;  (f)  incompetence  of  the  ileocecal  valve;  (g)  dilated 
duodenum  with  no  other  local  pathology. 

The  most  frequent  indirect  sign  of  appendicitis  or  even  pathology 
in  the  right  lower  quadrant  is  the  so-called  right-sided  position  of 
the  stomach.  We  frequently  are  able  to  suggest  from  the  first 
gastric  study  that  the  condition  is  one  of  right  quadrant  pathology 
from  the  fact  that  the  stomach  is  drawn  downward  and  far  to  the 
right. 

In  cases  where  the  appendix  cannot  be  seen,  one  is  justified  in 
suggesting  a  diagnosis  of  appendicitis  if  there  is  tenderness  of  the 
cecum  on  deep  pressure,  and  if  there  is  cecal  fixation  and  retention, 
or  cecal  spasm.  We  have  also  held  that  when  manipulation  of 
the  cecum  or  pressure  over  the  cecum  produces  pain  in  the  epigas- 
trium, in  the  absence  of  other  disturbances  a  condition  of  appen- 
dicitis is  probably  present. 

The  question  of  the  appendix  filling  with  barium  is  one  that  re- 
quiries  further  study.  It  is  claimed  by  some  workers  that  the  fact 
that  the  bismuth  enters  the  appendix  at  all  is  evidence  of  pathol- 
ogy. Others  hold  that  this  is  probably  normal  and  that  the  ques- 
tion of  pathology  is  dependent  entirely  upon  how  long  the  barium 
remains  in  the  appendix.  This  is  one  of  the  problems  which  we 
think  is  worthy  of  a  further  study. 

The  importance  of  appendiceal  retention  in  the  absence  of  appen- 


44       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

diceal  fixation  "or  tenderness  is  undetermined.  We  frequently  see, 
especially  in  the  aged,  appendiceal  retention  for  forty-eight  or 
seventy-two  hours,  and  as  far  as  we  can  determine,  there  were  no 
symptoms  whatever  from  the  appendix.  In  general,  however,  we 
can  state  that  an  appendix  which  retains  barium  after  the  cecum  is 
empty  can  be  definitely  classified  as  pathologic.  The  assumption 
that  a  diagnosis  of  appendicitis,  without  any  modifying  statement, 
follows  a  demonstration  of  any  of  these  conditions  is  no  more  cor- 
rect than  the  assumption  that  because  a  gallstone  has  been  demon- 
strated, there  is  no  other  abdominal  pathology,  or  even  that  the 
stone  is  of  diagnostic  importance.  In  our  opinion,  appendiceal  dis- 
ease is  quite  often  secondary  to  disturbances  of  the  terminal  ileum 
and  cecum,  and  appendicitis  simply  complicates  rather  than  is  the 
occasion  of  the  ileal  or  cecal  pathology.  This  error  explains  the 
large  number  of  appendectomies  which  fail  to  relieve  the  symptoms 
for  which  the  patient  was  operated. 

The  differential  diagnosis  between  gall  bladder  disease,  ureteral 
stone  and  appendicitis  is  greatly  aided  by  the  complete  roentgen 
study  of  the  right  side.  We  are  all  familiar  with  the  high  appendix 
which  gives  a  very  clear  clinical  picture  of  gall  bladder  disease,  and 
also  of  the  pathological  retrocecal  appendix  which  is  with  great  dif- 
ficulty differentiated  from  kidney  or  ureteral  disease. 

In  connection  with  the  colon,  the  most  important  condition  for 
the  internist  is  colonic  stasis.  The  most  common  cause  of  consti- 
pation, as  shown  by  the  roentgen  examination,  is  involvement  of 
the  pelvic  colon  in  adhesions.  Aside  from  the  fixation  of  the  bowe'. 
and  tenderness  associated  with  manipulation  of  the  part,  the  pres- 
ence of  spasticity  of  the  pelvic  colon  is  always  suggestive  of  adhe- 
sions. The  various  deformities  of  the  cecum,  cecal  fixation  and 
sharp  angulations  at  the  flexures  are  also  associated  with  disturbed 
colonic  motility.  The  diagnosis  of  carcinoma  or  other  new  growths 
involving  the  colon  are  diagnosed  by  the  demonstration  of  a  definite 
defect  in  bowel  outline  or  by  an  obstruction  produced  by  the  involve- 
ment of  the  lumen  with  the  tumor.  The  most  satisfactory  method  of 
examination  of  the  colon  for  new  growths  is  by  means  of  the 
opaque  enema. 

Numerous  cases  of  constipation  are  demonstrated  to  be  the  result 
of  definite  spasticity  of  the  colon.  It  is  our  observation  that  spastic 
constipation  results  in  reflex  gastric  symptoms  as  a  rule,  while 
general  colonic  statis  is  productive  of  symptoms  of  so-called  auto- 
intoxication. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      45 

As  to  the  study  of  the  colon  to  determine,  if  possible,  the  cause 
of  chronic  diarrhea,  the  association  of  this  condition  with  disei 
of  the  appendix  and  with  intestinal  stasis  is  relatively  common.    The 
intestinal  stasis  can  be  either  the  type  associated  with  spasticity  of 
the  colon  or  with  dilatation. 

I  realize  I  have  attempted  the  impossible  in  trying,  in  a  brief 
paper,  to  give  a  just  consideration  to  my  title.  Hut  I  sincerely  be- 
lieve that  if  the  internist  will  approach  the  subject  as  I  have  sug- 
gested and  become  familiar  with  the  full  possibilities,  and  learn 
to  correctly  associate  the  findings  with  the  pathology  and  symptoms, 
that  the  result  will  be  advantageous.  And  further,  there  should  be 
no  good  reason  for  postponing  the  roentgenological  examination 
until  all  other  tests  have  been  carried  out  or  diagnosis  postponed 
for  further  observation.  This  is  a  criticism  which  many  internists 
justly  deserve,  but  one  which  will  be  surely  avoided  when  the  aid 
we,  as  roentgenologists,  can  render,  is  fully  appreciated. 


THE   VALUE   AND   LIMITATIONS   OF  RADIOTHERAPY 
IN  INTERNAL  MEDICINE 

By  RUSSELL  H.  BOGGS 
Pittsburgh 

When  I  was  requested  to  discuss  the  value  and  limitations  of 
radiotherapy  to  internists,  I  at  once  appreciated  the  fact  it  was  not 
until  lately  that  the  internists  or  consulting  physicians  realized  the 
value  of  this  agent,  though  they  often  asked  for  a  surgical  con- 
sultation in  cases  which  were  in  no  manner  surgical.  When  you 
stop  to  consider  that  over  ninety  per  cent,  of  the  cases  of  tubercular 
adenitis  can  be  permanently  cured  by  the  roentgen  rays  without 
leaving  any  deformity,  that  the  symptoms  of  exophthalmic  goitre 
are  relieved  in  a  large  percentage  of  the  cases,  and  that  Hodgkin's 
disease  and  lympho-sarcoma  will  disappear  in  nearly  every  case  and 
are  not  any  more  prone  to  recur  than  after  a  surgical  operation, 
then  it  is  apparent  this  subject  must  be  carefully  studied  by  the 
internist  who  may  be  compelled  to  consult  with  someone  inex- 
perienced. No  one  who  has  seen  a  large  number  of  the  cases 
just  mentioned,  will  fail  to  realize  what  an  important  place  radium 
and  the  roentgen  rays  take  in  many  of  the  internal  diseases.  A 
great  deal  of  good  work  also  has  been  done  and  reported  on  dis- 


46      THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

eases  of  the  blood  and  blood  forming  organs,  the  value  and  signifi- 
cance of  which  is  not  generally  realized  by  the  medical  profession. 

To-day  the  internist  is  taking  perhaps  the  most  important  posi- 
tion in  the  practice  of  medicine,  and  consultation  with  him  is  certain 
to  be  of  supreme  importance  in  this  class  of  cases.  The  internist 
should  be  as  adept  in  what  can  be  accomplished  by  radiotherapy 
as  the  surgeon  should  be  in  cancer.  Most  internists  would  not  want 
to  decide  on  what  should  be  done  with  cancer  patients,  and  most 
surgeons  should  not  want  to  decide  with  the  so-called  internal  dis- 
eases. In  the  early  clays  of  radiotherapy,  before  it  had  become  a 
specialty,  this  branch  of  medicine  was  usually  left  to  the  surgical 
side  of  the  hospital.  It  was  very  often  forced  upon  the  assistant 
surgeon  who  was  interested  in  surgery  instead  of  radiotherapy, 
and  he  frankly  stated  that  he  had  no  interest  in  this  department. 
Consequently  he  never  studied  the  technic  and  usually  did  poorer 
work  after  two  or  three  years'  experience  than  he  did  at  first.  The 
assistant  to  the  internist  to-day  would  be  in  the  same  position. 
Fortunately,  it  is  realized  that  radiotherapy  has  become  a  strict 
specialty.  Unfortunately  much  of  the  work  is  being  done  by  be- 
ginners without  a  consultation  with  someone  who  has  had  the 
proper  experience. 

In  order  to  determine  the  therapeutical  value  of  the  roentgen  rays, 
it  is  necessary  to  study  their  physiological  action.  It  has  been 
demonstrated  that  the  same  percentage  of  roentgen  rays  effect  tissues 
differently,  and  this  explains  how  lymphatic  glands  will  undergo  a 
degeneration,  with  almost  an  entire  obliteration  of  the  chain,  with- 
out seriously  influencing  the  surrounding  tissues.  All  tissues  which 
have  undergone  pathological  changes  react  more  quickly  and  in- 
tensely. Both  macroscopical  and  microscopical  examinations  show 
how  the  rays  act  on  the  pathological  and  normal  tissue.  The  select- 
ive action  of  the  rays  for  epithelial  cells  explains  how  certain  dis- 
eases are  cured  while  others  are  unaffected. 

The  activity  of  development  of  the  cellular  constituents  of  a 
part  and  the  amount  of  cellular  proliferation  modify  the  reaction. 
The  more  active  the  cellular  proliferation,  the  more  readily  the 
cells  respond  to  radiation.  The  stage  of  maturity  to  which  the 
cells  have  attained  has  a  decided  influence  upon  the  cellular  reac- 
tion ;  and  in  the  case  of  epithelial  and  endothelial  cells,  it  has  been 
found  that  cells  fully  matured  react  less  readily  than  those  in 
the  process  of  development.  The  fully  matured  lymphocytes 
and   leucocytes   respond   readily,   while   arrest  of   development  and 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      47 

retrogressive    changes    only    are    produced     in     the    immature. 

The  only  appreciable  result  of  radiation  upon  the  red  blood  cor- 
puscles is  a  decrease  in  their  physical  resistance;  no  alteration  in 
the  haemoglobin  has  yet  been  established.  The  white  cells,  on 
the  other  hand,  are  very  susceptible  to  radiation,  the  leucocytes 
showing  marked  degenerative  changes,  mainly  in  the  direction  of  the 
fragmentation  of  the  nucleus.  The  protoplasm  of  the  cells,  more 
particularly  of  the  poly  nuclear  variety,  undergo  a  degenerative 
change,  being  broken  up  into  small  masses,  which  either  refuse  to 
stain  or  stain  badly.  This  plainly  shows  that  their  physiological 
evolution    is   hastened. 

The  epithelial  cells,  both  cutaneous  and  parenchymatous,  are 
affected  in  proportion  to  their  vitality.  Dead  cells  are  unaffected, 
fully  matured  cells  are  very  resistant,  and  the  more  embryonic  forms 
of  cells  are  more  easily  affected,  a  retardation  in  development  pre- 
ceding degenerative  metamorphosis.  Where  healthy  structures 
are  exposed  to  the  action  of  the  rays,  the  primary  changes  of 
degeneration  and  destruction  of  the  epithelial  cells  have  been  found 
to  precede  proliferation  of  the  connective  tissues,  the  vascular 
changes  being  a  later  manifestation  of  radiation. 

In  applying  the  rays,  it  is  hardly  necessary  to  state  that  the 
severity  of  the  reaction  can  be  varied  from  a  mild  erythema  to 
necrosis,  according  to  the  kind  and  amount  of  rays  absorbed. 

GOITRE 

Tremendous  advancement  has  been  made  in  recent  years  in  our 
knowledge  of  the  physiology,  pathology  and  treatment  of  the  duct- 
less glands.  Improvement  has  been  shown  in  exophthalmic  goitre 
by  treating  either  the  thyroid,  thymus  or  ovaries  alone,  but  until 
lately  in  most  of  the  cases,  the  thyroid  alone  had  been  treated.  It 
is  known  that  thyroidectomy  does  not  always  remove  all  the  symp- 
toms of  Graves'  disease  and  that  many  times  the  patient  is  greatly 
benefited  by  roentgen  treatment  of-  the  thymus  and  ovaries  after- 
wards. Many  of  the  European  investigators  consider  hyperplasia 
of  the  thymus  closely  allied  with  exophthalmic  goitre,  and  some 
have  reported  that  the  thymus  is  enlarged  in  ninety  per  cent,  of 
cases.  Attention  has  been  called  to  the  fact  that,  when  the  thymus 
gland  is  greatly  enlarged,  the  patients  do  not  stand  operation  well 
and  that  such  patients  suffer  severe  shock  from  operation,  some- 
times followed  by  death.  Since  the  thymus  gland  seems  to  play 
such  an  important  part  in  producing  the  symptoms  of  Graves'  dis- 


48       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

ease  and  the  danger  from  operation  is  greater  when  the  thymus  is 
enlarged,  roentgen  treatment  of  the  thymus  at  least  should  be 
given. 

Goitre  has  been  divided  into  three  groups :  first,  the  ordinary 
type  or  adenoma,  which  does  not  produce  any  symptoms  except 
enlargement  of  the  thyroid  gland  and  is  often  accompanied  by  more 
or  less  nervous  symptoms ;  second,  the  simple  goitre,  with  begin- 
ning toxic  symptoms ;  and  third,  enlargement  of  the  thyroid,  often 
accompanied  by  changes  in  other  ductless  glands,  with  typical 
symptoms  of  exophthalmic  goitre. 

There  are  three  well  known  forms  of  treatment  of  goitre  at  the 
present  time ;  namely,  medical,  roentgenological  and  surgical.  The 
medical  should  always  be  considered  first,  as  changes  in  the  thyroid 
gland  are  produced  by  various  conditions  such  as  infections,  fatigue, 
pregnancy,  shock,  etc.,  and  many  times  the  symptoms  will  dis- 
appear when  the  patient  is  kept  at  rest  under  medical  treatment. 
There  is,  however,  no  question  that  treating  a  case  too  long  medi- 
cally may  be  followed  by  permanent  damage  to  various  structures 
of  the  body,  and  since  roentgen  treatment  has  proved  efficient  and 
is  not  dangerous  in  the  hands  of  a  skilled  roentgen  therapeutist, 
there  is  no  necessity  of  delaying  the  treatment  too  long. 

Now  with  our  present  knowledge  of  roentgen  rays  in  the  treat- 
ment of  goitre,  patients  should  never  be  allowed  to  reach  a  pre- 
carious stage  before  this  method  of  treatment  has  at  least  been 
given  a  fair  trial.  Treating  the  thymus  and  ovaries  is  not  suffi- 
cient, but  the  thyroid  should  usually  receive  the  greater  propor- 
tion of  the  treatment.  Often  patients  suffering  from  goitre  in  the 
advanced  stage  are  very  easily  discouraged,  and  to  avoid  disap- 
pointments it  is  important  that  you  should  have  a  thorough  under- 
standing with  the  patient  before  treatment  is  given. 

Patients  with  simple  goitres,  having  only  enlargement  of  the 
gland  and  accompanied  by  nervous  symptoms,  will  receive  much 
benefit  from  a  few  roentgen  treatments.  The  enlargement,  which 
may  be  only  in  one  lobe  can  be  checked  and  reduced  in  size,  and 
the  patient's  health  will  be  greatly  improved.  Raying  a  lobe  of  the 
thyroid  is  not  any  more  dangerous  than  removing  it  surgically, 
because  if  the  treatment  is  given  carefully  you  can  stop  on  the  safe 
side.  In  cases  of  simple  goitre,  which  are  just  beginning  to  show 
symptoms  of  the  exophthalmic  type,  roentgen  treatment  should 
be  given  at  once,  followed  up  by  one  or  two  series,  because  nearly 
all  of  these  will  be  promptly  relieved. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      49 

In  the  exophthalmic  type,  in  which  the  symptoms  are  marked 
and  damage  has  been  done  to  other  structures  of  the  body,  we  must 
be  careful  in  giving  a  prognosis  as  well  as  in  giving  the  roentgen 
treatment.  The  gland  in  these  cases  is  often  easily  affected,  and  the 
patient  may  be  suffering  from  damage  of  the  heart,  nervous  sys- 
tem, etc.,  and  instead  of  hyper-secretions  of  the  thyroid  entirely, 
the  patient  is  almost  ready  to  pass  from  a  hyper  into  a  hypo  con- 
dition.    Then  very  heavy  roentgen  treatment  is  contra-indicated. 

Since  radium  has  been  used  in  sufficient  quantities,  and  screen- 
ing and  cross-firing  have  been  employed,  goitre  has  been  successfully 
treated  with  radium.  The  results  by  radium  are  about  the  same  as 
those  produced  by  the  roentgen  rays.  Possibly  if  large  doses  of 
radium  are  employed,  properly  screened  and  placed  at  the  proper 
distance,  the  symptoms  respond  slightly  quicker  than  when  the 
roentgen  rays  are  used.  Radium  has  the  advantage  that  it  can  be 
employed  without  moving  the  patient. 

The  first  improvement  noted  is  the  reduction  of  the  pulse  rate. 
Various  authorities  have  found  the  decrease  in  pulse  rate  in  ninety 
per  cent,  of  the  cases,  and  it  is  possibly  the  best  guide  we  have  in 
regard  to  giving  the  treatment,  because  it  has  been  pointed  out 
that  the  stability  of  the  pulse  is  as  important  as  the  reduction  it- 
self ;  that  is,  when  it  does  not  fluctuate  with  exertion  or  excite- 
ment. I  have  found  that  an  increase  in  weight  occured  in  at  least 
one-half  to  three-fourths  of  the  cases  after  the  first  series  of 
roentgen  treatments.  As  soon  as  the  pulse  rate  is  reduced  and 
becomes  more  or  less  stable  and  the  patient  increases  in  weight,  the 
nervous  symptoms,  such  as  excitability,  insomnia,  etc.,  improve 
rapidly.  The  exophthalmos  improved  in  many  of  the  cases  which 
I  treated.  Some  authorities  state  that  improvement  is  noted  in 
fifty  per  cent,  of  such  cases.  In  my  cases  there  was  a  reduction  of 
the  thyroid  gland,  at  least  to  a  certain  extent,  in  over  two-thirds  of 
the  cases  of  the  exophthalmic  type,  and  in  about  one-half  of  the 
cases  the  reduction  was  very  marked.  As  before  stated,  we  must 
go  cautiously  and  when  the  hyper-secretion  is  reduced  to  normal, 
we  must  stop  treatment,  regardless  of  the  size  of  the  thyroid,  be- 
cause if  carried  further  there  is  a  danger  of  producing  myxedema. 

There  is  a  class  of  cases  in  which  the  value  of  roentgen  therapy 
is  too  little  appreciated  even  by  men  practiced  in  its  use,  which  in- 
cludes the  small  or  moderate  sized  goitre  of  adolescent  females  with 
few  or  no  symptoms.  Hitherto  the  best  advice  we  could  give  these 
cases  was  to  let  their  goitres  alone.    Medical  treatments  offered  them 


50       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

a  problematical  result  and,  since  the  cosmetic  consideration  was  of 
chief  concern,  a  surgical  operation,  with  its  resulting  scar,  was  con- 
sidered with  reluctance.  Moreover,  the  majority  of  these  goitres 
disappear  spontaneously  in  a  few  years  or  in  a  few  months.  It  is 
true  we  are  unable  to  say  which  cases  belonged  to  the  majority 
that  would  be  cured  by  nature's  own  method  or  which  ones  would 
go  on  to  a  life-time  of  chronic  hyperthyroidism,  and  the  conversion 
of  glandular  into  cystic  tissue,  with  its  resulting  permanent  unsightly 
tumor  which  is  always  a  potential  danger  by  reason  of  mechanical 
pressure.  In  several  such  cases  I  undertook  roentgen  treatment, 
somewhat  reluctantly,  merely  to  secure  a  cosmetic  effect.  I  was 
amazed  to  find  that  the  treatment  resulted  not  only  in  a  distinct 
gain  of  weight  and  bodily  strength,  but  also  in  the  correction  of  a 
psychic  instability  which  had  been  looked  on  as  a  matter  of  charac- 
ter rather  than  disease. 

When  it  becomes  the  custom  to  regulate  by  judicious  roentgeniza- 
tion,  even  minor  abbreviations  of  thyroid  function  appearing  at  ado- 
lescence, I  believe  we  will  not  only  prevent  the  chronic  hyperthy- 
roids  and  disfiguring  cystic  goitres  of  later  life,  but  also  add 
appreciably  to  the  health  and  welfare  of  the  community. 

The  treatment  of  goitre  is  major  roentgenological  work  and 
should  not  be  attempted  by  anyone  unless  he  is  familiar  with  his 
technic  and  knows  the  physiology  and  pathology  and  needs  of  a 
clinical  study  of  the  ductless  glands.  A  decrease  in  the  pulse  rate 
and  an  increase  in  weight  are  the  first  improvements  noted.  Reduc- 
tion of  the  thyroid  is  not  always  marked  when  all  the  symptoms 
have  disappeared  and  the  exophthalmos  is  the  last  to  show  improve- 
ment. Sufficient  results  have  been  produced  to  give  all  cases  a  fair 
trial  because  nothing  is  lost  thereby  and  many  operations  will  be 
avoided.  If  the  patient  is  greatly  relieved  after  the  first  series  of 
treatments,  you  must  not  consider  the  patient  cured  at  this  stage. 
It  is  to  be  expected,  if  it  is  necessary  to  operate,  the  mortality  will 
be  lessened  by  preliminary  roentgen  treatment.  The  aim  is  to  pro- 
duce sufficient  atrophy  of  the  thyroid,  so  that  it  will  produce  a 
healthy  amount  of  secretion  and  no  more. 

OTHER  GLANDULAR  TUMORS 

Multiple  glandular  tumors,  including  tubercular,  sarcoma,  Hodg- 
kin's  disease,  lymphatic  leukemia,  primary  carcinoma  and  syphilis, 
are  at  times  difficult  or  impossible  to  diagnose  clinically.  A  series 
of  successfully  treated  tubercular  adenitis  cases  will  undoubtedly  in- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE       51 

elude  a  small  percentage  of  cases  which  were  not  tubercular.  It  is 
impossible  to  make  an  exact  classification  clinically,  and  even  at 
times,  pathologically.  It  is  rather  striking  how  similar  are  the  results 
in  the  treatment  of  many  of  these  conditions,  even  if  the  glands  have 
been  excised  and  a  pathological  examination  made. 

While  the  roentgen  rays  are  indicated  in  all  of  the  glandular  dis- 
.  eases  mentioned,  with  the  exception  of  syphilis,  my  experience  has 
been  that  Hodgkin's  disease  responds  quicker  to  the  roentgen  rays, 
and  also  is  more  likely  to  recur  than  any  other  disease  mentioned. 
A  large  tuberculous  mass  of  glands  will  not  respond  to  the  same 
amount  of  treatment  as  Hodgkin's  disease  or  sarcoma,  but  after 
they  are  clinically  cured,  the  result  is  more  permanent.  In  Hodg- 
kin's disease,  the  enlargement  can  be  made  to  disappear  entirely, 
but  usually  within  a  short  time  after  the  treatment  there  may  be  a 
recurrence,  and  it  is  necessary  to  keep  raying  the  patient  at  frequent 
intervals  to  keep  down  the  enlargement.  In  this  disease  a  patient, 
emaciated  and  bedridden  may,  by  the  treatment,  not  only  show  a 
temporary  disappearance  of  the  glands,  but  may  even  resume  his 
occupation  for  a  time.  As  soon  as  any  recurrence  is  noticed,  treat- 
ment should  be  administered  and,  as  a  rule,  the  external  tumors 
can  be  controlled  for  a  long  time  or  until  the  patient  succumbs  to 
deep  involvement. 

Lympho-sarcoma  in  which  the  disease  disappears  under  roentgen 
treatment  is  usually  slower  to  recur  in  comparison  to  Hodgkin's 
disease.  However,  the  results  do  not  compare  with  those  in  the 
cases  diagnosed  as  tuberculous  glands,  but  I  have  patients  apparently 
well  for  three  years  in  whom  a  gland  had  been  removed  and  a 
pathological  diagnosis  of  lympho-sarcoma  made.  One  case  lived 
seven  years  where  the  diagnosis  had  been  made  at  the  Mayo  clinic 
and   operation   was   refused. 

In  most  cases  of  both  lympho-sarcoma  and  Hodgkin's  disease, 
the  glands  can  be  made  to  disappear  under  proper  treatment  and  do 
not  recur  nearly  so  quickly  as  when  they  are  removed  surgically. 

In  tubercular  adenitis  the  severity  of  the  process  ranges  from 
large  broken  down  glands  and  large  glands  not  broken  down  to 
glands  almost  invisible.  The  rapidity  of  results  is  most  striking 
in  the  large  broken  down  glands  and  it  is  particularly  interesting  to 
note  that  most  of  these  cases  were  just  as  permanently  benefited  as 
in  the  cases  where  the  glands  were  only  of  small  size.  In  com- 
parison to  the  size  of  the  glands  it  requires  less  treatment  to  reduce 
the  mass,  when  the  glands  are  large  and  broken  down,  or  about  to 


52       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

break  down.  Strange  as  this  may  seem,  it  is  true,  but  we  are 
unable  to  account  for  this,  unless  it  is  due  to  the  fact  that  there  is 
so  much  more  glandular  tissue  present  in  the  large  tumor  which  is 
more  easily  affected  by  the  roentgen  rays.  Most  likely,  there  is 
a  constitutional  effect,  and  this  is  most  pronounced  when  a  large 
amount  of  tuberculous  tissue  is  rayed,  as  well  as  the  fact  that  the 
tissue  is  of  lower  vitality  than  in  the  smaller  glands.  These  facts 
suggest  that,  in  the  destruction  of  tissue,  an  autogenous  vaccine 
is  set  free. 

Ten  or  twelve  years  ago  tubercular  adenitis  was  referred  on 
account  of  the  treatment  leaving  no  unsightly  scar,  but  to-day  the 
chief  reason  is  that  there  are  fewer  recurrences  and  less  danger 
of  a  general  tuberculosis,  also  a  larger  number  of  cases  are  perma- 
nently cured.  The  diseased  glands  are  of  much  wider  distribution 
than  the  clinical  signs  indicate,  and  local  lesions  are  often  of  such 
a  character  or  so  situated  that  they  are  difficult  or  even  impossible 
to  reach  by  any  other  method  than  roentgen  therapy. 

It  is  claimed  that  at  least  ninety  per  cent,  of  these  cases  can  be 
permanently  cured  by  radiation.  There  are  many  roentgenologists 
who  have  treated  300  or  400  cases  successfully,  covering  sufficient 
length  of  time  to  justify  us  in  advising  radiotherapy  as  a  routine 
method  of  treatment.  At  present  this  is  admitted,  even  among 
many  of  the  most  conservative  physicians.  Reliable  observers  notice 
great  differences  in  the  percentage  of  successes  and  of  failures.  The 
reason  for  these  clinical  differences  can  be  pointed  out  when  we 
study  the  different  methods  of  treatment. 

The  insertion  of  a  tube  of  radium  in  a  tubercular  sinus  will  often 
heal  it  promptly  and  save  removal.  I  have  done  this  in  a  few  cases 
and  when  the  reaction  disappeared  the  sinus  was  nearly  healed. 
I  believe  this  would  be  a  dangerous  procedure  unless  the  entire 
chain  of  glands  had  first  been  rayed  and  the  tuberculosis  in  the 
glands  nearly  all  destroyed. 

Tubercular  adenitis  is  treated  somewhat  differently  from  malig- 
nancy, the  same  as  quinine  or  the  iodides  are  used  in  different 
diseases.  It  has  often  been  noted  that  tuberculous  glands  in  chil- 
dren whose  tonsils  were  enlarged,  were  improved  after  radiation 
to  such  an  extent  that  it  was  not  necessary  to  remove  them.  Many 
do  not  advise  the  removal  of  diseased  tonsils  in  children  with 
tubercular  adenitis,  and  some  surgeons  even  claim  that  such  a 
procedure  aggravates  a  tuberculous  adenitis.  Many  surgeons  do  not 
advise  complete  extirpation  of  the  involved  glands  when  they  are 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      53 

not  well  localized  because  they  are  afraid  of  setting  up  a  general 
tuberculosis.  This  is  mentioned  by  Dr.  DeCosta,  Attridge  and 
others. 

In  writing  of  the  surgical  treatment  of  tuberculous  adenitis, 
Mathews,  in  Johnson's  "Surgery,"  states :  "There  is  a  widespread 
notion  that  surgical  treatment  is  inefficient,  that  glands  recur  even 
at  the  site  of  a  previous  operation,  so  that  when  operation  is  rec- 
ommended it  is  to  be  looked  upon  as  but  the  beginning  of  a  series 
of  operations." 

Von  Mutschenvacker  offers  conservative  treatment  of  tuberculous 
adenitis,  and  states  that  he  has  operated  in  only  nine  per  cent,  of 
1344  cases.  He  recommends  the  roentgen  rays  and  compares 
roentgen  tberapy  favorably  with  surgery.  He  believes  that  the  rays 
cause  a  disappearance  of  the  adenoid  tissue,  leaving  only  the  stroma. 

LEUKEMIA 

A  large  number  of  cases  of  leukemia  have  been  treated,  and  while 
radiotherapy  offers  more  than  any  other  method,  the  end  results 
are  usually  unfavorable.  At  first  roentgen  treatment  appears  to 
be  favorable,  and  often  a  symptomatic  or  clinical  cure  is  obtained. 
The  fact  still  remains  that  radiotherapy  is  the  most  successful 
therapeutic  agent  yet  discovered,  but  the  first  results  are  but  tem- 
porary, and  the  treatment  invariably  fails  to  prevent  the  usual  fatal 
termination. 

It  is  remarkable  how  the  spleen  and  lymphatic  glands,  as  well  as 
the  blood  count  will  improve  after  a  few  roentgen  treatments  are 
given.  Many  clinical  cures  are  obtained,  lasting  from  a  few  months 
to  seven  or  eight  years,  but  still  we  must  always  give  a  guarded 
prognosis  in  leukemia,  because  we  can  never  tell  when  a  relapse 
will  take  place.  On  this  account  we  must  regard  the  treatment 
as  merely  a  palliative  measure.  This  is  no  reason  for  us  not  fol- 
lowing up  the  treatment  as  thoroughly  as  possible. 

In  the  past  many  have  only  partially  treated  their  cases,  in  that 
they  were  not  kept  under  careful  observation,  and  roentgenization 
was  not  given  from  time  to  time  as  is  advocated.  On  account  of 
the  bone  marrow,  spleen  and  glands  being  effected  by  the  disease, 
it  can  be  readily  seen  how  extensive  the  treatment  must  be  since 
it  has  the  malignant  tendency  to  recur ;  the  treatment  should  be  re- 
peated, of  course  within  the  bounds  of  safety.  The  most  successful 
cases  are  usually  those  in  which  the  treatment  is  carried  out  the 
most  thoroughly.     One  of   the  most   striking  cases  which   I   have 


54       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

treated  was  bedfast  when  treatment  was  begun.  After  a  short  time 
she  was  up  tending  to  her  usual  duties,  continuing  treatment  at 
intervals.  She  was  apparently  well  for  four  years,  but  during  the 
next  two  years  she  did  not  show  the  same  marked  effect  from  the 
roentgen  rays.  Possibly  more  will  be  obtained  in  the  future  when 
more  roentgenologists  make  a  careful  study  of  this  subject.  Pan- 
coast,  at  one  of  the  recent  meetings  of  the  American  Roentgen 
Ray  Society,  criticized  the  members  because  so  few  of  them  had 
paid  sufficient  attention  to  this  very  important  subject. 

Drug  therapy,  except  arsenic  which  occasionally  exercises  inhibi- 
tion or  possibly  a  curative  effect,  is  valueless.  Benzol  has  produced 
a  few  temporary  results,  but  when  they  are  carefully  compared 
in  a  large  number  of  cases  with  the  roentgen  rays,  the  later  are 
not  only  superior,  but  are  more  lasting. 

Permit  me  to  quote  a  paragraph  from  Pancoast  who  has  worked 
on  leukemia  in  conjunction  with  Stengel  for  a  number  of  years. 
They  have  carefully  tabulated  and  studied  their  cases,  and  state  their 
conclusions  as  follows : 

"We  are  still  obliged  to  regard  leukemia  as  ultimately  an  in- 
curable disease  and  to  be  satisfied  with  a  prognosis  which  implies 
a  prolongation  of  life  from  a  few  months  to  six  or  eight  years, 
during  a  period  of  comparative  comfort,  partly  taken  up,  however, 
by  intervals  of  treatment  for  threatened  or  active  relapses.  The 
evidences  of  cure  and  experience  are  to  be  found  in  the  extent  of 
prolongation  of  life,  the  comfort  and  strength  of  the  patient  and 
ability  to  attend  to  business  or  work,  and  the  freedom  of  a  period 
of  observation  from  frank  relapses.  Successful  results  require  care 
in  the  preliminary  treatment  of  the  active  period  of  the  disease, 
persistence  in  treatment  until  every  manifestation  has  disappeared,  a 
careful  watch  over  the  patient  thereafter,  and  a  resumption  of  appli- 
cations on  the  appearance  of  the  first  evidences  of  a  relapse.  The 
first  indications  of  a  relapse  are  changes  in  the  differential  count  or 
a  slight  rise  in  the  leucocyte  count,  or  both." 

Remission  in  leukemia  following  radium  treatment  has  taken  place 
in  cases  which  did  not  respond  to  the  roentgen  rays.  Whether 
radium  is  superior  to  the  roentgen  rays  is  difficult  to  determine,  as 
a  difference  in  technic  may  have  been  the  reason  for  the  different 
results  in  the  cases  reported.  It  would  appear  that  the  roentgen 
rays  should  be  applied  to  the  skeleton,  as  it  is  generally  conceded 
that  the  primary  lesion  starts  in  the  marrow  of  the  bones,  even  if 
radium  is  superior  when  treating  -the  spleen  or  lymphatic  glands. 


THE  AMERICAN  CONGRESS  OX  INTERNAL  MEDICINE      55 

Remissions  in  leukemia  have  taken  place  following  injections  of 
thorium.  In  certain  cases,  it  may  be  advisable  to  use  radium  over 
the  spleen  or  glands  and  treat  the  entire  skeleton  with  the  roentgen 
rays.  Giffin,  from  the  department  of  medicine.  Mayo  Clinic,  re- 
ported thirty  consecutive  cases  of  myelocytic  leukemia  treated  by 
radium,  using  surface  application  as  described  by  ( )rdway.  They 
were  all  treated  between  May  1916  and  April  1917.  but  the  time 
is  too  short  to  consider  anything  except  the  temporary  effects.  He 
concludes  as  follows : 

"Surface  exposures  of  radium  over  the  spleen  of  myelocytic 
leukemia  usually  effect  a  very  rapid  reduction  of  the  size  of  the 
spleen,  a  fall  of  the  leukocyte  count,  improvement  in  the  general 
condition  and,  together  with  transfusion,  constitute  at  present  the 
most  effective  temporary  measure  in  the  treatment  of  the  disease." 

I  shall  not  attempt  to  discuss  the  excellent  work  which  has  been 
done  in  fibroids  of  the  uterus,  where  Koenig  and  Gauss  report 
almost  100  per  cent,  of  cures.  Carcinoma  and  other  diseases  will 
be  omitted,  as  each  would  be  papers  in  themselves. 

Dr.  E.  H.  Bartley  :  I  noted  that  Dr.  Johnston  made  the  remark 
that  he  had  never  come  across  a  case  of  primary  carcinoma  of  the 
lungs.  I  would  like  to  mention  in  the  connection  that  two  years  ago  I 
came  across  a  case,  which,  in  spite  of  all  investigations  for  a  primary 
focus  elsewhere,  appeared  to  be  a  primary  carcinoma  originating  in 
the  bronchial  gland.  A  thorough  examination  was  made  at  autopsy 
and  no  other  point  of  involvement  was  discovered.  I  am  not  able 
to  say  whether  this  is  a  very  rare  instance,  but  it  seems  worth  while 
to  mention  it  in  connection  with  this  paper  which  Dr.  Johnston  has 
presented. 

In  regard  to  the  question  of  the  use  of  the  x-ray  in  the  diagnosis 
of  pneumonia,  Dr.  Johnston  has  mentioned  central  involvement. 
I  have  been  for  a  number  of  years  chiefly  interested  in  cases  of 
pneumonia  occurring  in  children.  In  this  type  the  disease  certainly 
does  begin  at  the  periphery  and  it  extends  toward  the  hilus ; 
although  I  am  not  prepared  to  say  that  it  does  the  same  thing  in 
adults.  In  children  the  physical  signs  occur  only  when  the  disease 
reaches  the  bronchi.  There  is  no  such  thing  as  central  pneumonia 
in  young  subjects.  The  x-ray  shows  that  the  disease  begins  at  the 
pleurae  and  extends  inward.  I  don't  know  why,  in  these  so-called 
central  pneumonias,  that  there  appear  evidences  of  delirium  and 
toxemic  conditions.     Often  these  cases  die  without  a  definite  diag- 


56       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

nosis  having  been  made.  They  are  supposed  to  be  central  pneu- 
monias. The  x-ray  should  be  of  service  in  determining  pneumonia 
when  physical  signs  are  absent. 

In  the  forenoon  of  December  28,  1917,  clinics  were  held  at  the 
Mercy  Hospital,  Pittsburgh,  during  which  many  interesting  patients 
were  presented  by  the  medical  staff  of  that  institution,  and  the  cases 
discussed  by  the  members  of  the  congress. 


COMMUNICABLE    DISEASES    AMONG    THE    SOLDIERS 
IN  ENGLAND  AND  FRANCE 

By  W.  H.  PARKS 

In  Europe,  as  in  America,  we  find  that  great  bodies  of  men  are 
collected  in  companies  for  training.  Those  who  come  from  cities 
have,  as  a  rule,  had  the  ordinary  communicable  diseases,  such  as 
measles,  whooping  cough,  mumps,  and  have  been  exposed  to  the 
others,  such  as  diphtheria  and  scarlet  fever.  Many,  however,  come 
from  small  hamlets  or  towns  in  which  one  or  more  of  these  diseases 
has  not  been  prevalent  for  years.  When  such  men  mingle  together, 
there  is  great  opportunity  of  infection  if  the  chance  offers  and  we 
find,  in  the  training  camps  abroad  as  in  the  states,  that  measles, 
mumps  and,  to  a  less  extent,  scarlet  fever,  whooping  couph  and 
chickenpox  prevail.  When  these  men  have  passed  the  period  of 
training  and  are  ready  to  go  into  active  service,  they  have,  as  a  rule, 
been  protected  by  having  had  these  diseases  either  before  entering 
camp  or  afterward,  and  there  is  comparatively  little  of  such  in- 
fections at  the  front.  Nevertheless,  here  and  there  small  outbreaks 
do  occur  which  interfere  considerably  with  the  active  service  of  the 
troops.  The  diseases  other  than  wound  infections  which  are  most 
important  in  France  and  England  are  pneumonia  and  other  repira- 
tory  diseases,  meningitis,  diphtheria,  dysentery  and,  in  the  more 
southern  climates,  malaria.  The  troops  in  France  have,  fortunately, 
been  protected  from  exposure  to  typhus  fever  and  cholera  and  by 
vaccination   from  typhoid   fever. 

The  amount  of  tuberculosis  among  the  troops  at  camp  and  the 
troops  at  the  front  is  disputed.  In  England,  there  is  no  increase 
in  the  camps  and  there  is  certainly  no  great  development  of  tuber- 
culosis among  the  troops  at  the  front.  Among  the  French,  it  is 
very  difficult  to  decide  on  account  of  the  lack  of  informatoin  as  to 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      57 

the  amount  of  tuberculosis  among  the  civil  population  of  France 
and  the  fact  that  the  men  were  called  so  suddenly  to  withstand  the 
German  attack,  that  no  proper  physical  examination  could  be  made 
of  the  troops.  Examinations  at  the  front  have  apparently  revealed 
a  good  deal  of  incipient  tuberculosis  and  some  advanced  tubercu- 
losis. Many  of  those  sent  home  as  incipient  cases  have  after  very 
careful  examinations  made  at  the  receiving  hospitals  been  discharged 
as  not  having  the  infection.  Trench  fever  has  been  more  interesting 
than  important. 

Two  diseases  were  prominent  at  the  beginning  of  the  war  on 
account  of  the  infection  of  wounds  through  the  dirt.  These  two, 
tetanus  and  gas  gangrene  are,  of  course,  not  communicable  under 
ordinary  conditions  from  person  to  person.  The  surgical  care  of 
wounds  has  largely  eliminated  gas  gangrene,  and  the  use  of  anti- 
toxin, the  development  of  tetanus. 

There  was  at  first  a  great  deal  of  typhoid  fever  and  probably 
also  of  paratyphoid  fever.  Happily  vaccination  has  largely  re- 
duced these  infections. 

Malaria  was  of  little  importance.  What  did  occur  was  mostly 
relapses  among  those  who  had  received  their  infections  in  Turkey 
and  Greece.  In  those  countries  malaria  was  frequent  and  severe. 
The  diseases  which  were  being  combatted  with  newrer  methods  were 
meningitis,  pneumonia,  typhoid  fever,  paratyphoid  fever,  dysentery 
and  tetanus.  The  time  at  my  disposal  will  be  taken  up  in  their 
consideration. 

CEREBROSPINAL    MENINGITIS 

Its  Prevention  and  Treatment.  This  disease  has  been  quite  prev- 
alent among  the  troops  in  the  training  camps  in  England  and 
Canada  and  somewhat  so  among  the  English  and  French  troops  in 
France  and  the  Australian  and  New  Zealand  troops  in  home  camps 
and  on  the  transports. 

Among  the  English  troops  alone,  there  were  some  3000  cases 
during  1915.  The  disease  was  somewdiat  less  prevalent  in  1916 
but  was  again  serious  in  1917.  The  civil  population  was  only 
slightly  affected.  Each  year  the  greatest  number  of  cases  occurred 
in  February,  March  and  April.  The  seriousness  of  the  outbreak 
developing  in  England  in  1915  caused  a  very  thorough  investiga- 
tion of  the  means  of  spread  of  the  disease  and  the  best  methods  of 
prevention  and  cure.  The  outcome  of  the  investigation  has  been 
made  public  by  the  British  Medical  Research  Committee  and  by 


58       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

reports  from  individual  workers  such  as  Gordon,  Eastwood,  Tul- 
lock,  Griffith  and  Scott. 

The  information  obtained  corroborated  the  statements  made  by 
Bolduan  and  Goodwin  of  the  New  York  City  Bacteriological  Lab- 
oratories in  1906  as  to  carriers  and  those  of  the  Rockefeller  Insti- 
tute and  the  Health  Department  Laboratory  as  to  the  value  of 
serum  and  the  different  strains  of  meningococci.  The  work  of 
the  English  Research  Commission  has,  however,  taken  up  much 
more  thoroughly  and  probably  successfully  the  treatment  of  car- 
riers by  the  use  of  antiseptic  sprays. 

The  general  results  of  the  English  investigations  are  as  follows : 

Factors  influencing  the  incidence  of  the  disease.  Whenever  cases 
developed  among  the  troops  bacterial  examination  of  contact  per- 
sons revealed  that  there  were  many  carriers  for  each  case.  As  in 
pneumonia,  diphtheria,  infantile  paralysis  and  many  other  dis- 
eases, so  it  is  in  cerebrospinal  meningitis  that  only  a  few  of  those 
who  receive  the  infecting  organism  and  in  whom  it  gains  a  foot- 
hold in  the  mucous  membranes  become  truly  invaded  and  ill.  Those 
persons  who  become  carriers  seem  to  be  in  almost  no  danger  of 
contracting  the  disease.  The  fact  that  a  person  carries  the  menin- 
gococcus in  his  nasopharynx  for  a  number  of  days  without  deeper 
infection,  almost  proves  immunity. 

The  abundance  of  carriers  and  of  cases  depends  chiefly  on  the 
virulence  of  the  organism,  the  susceptibility  of  the  population  and 
the  atmospheric  conditions.  The  season  of  the  year  is  of  the  ut- 
most importance.  The  importance  of  the  susceptibility  of  a  pop- 
ulation which  has  not  been  subject  to  infection  was  clearly  brought 
out  by  the  recent  epidemic  among  the  blacks  in  British  South  Africa 
where  the  proportion  attacked  was  much  greater  than  ever  occurs 
among  the  white  troops. 

The  carrier  rate  has  been  found  to  vary  in  different  localities 
and  at  different  seasons  of  the  year.  This  has  been  true  in  both 
England  and  France.  In  parts  of  England  where  the  disease  is 
endemic  but  not  epidemic  about  two  per  cent,  of  the  tested  cases  has 
been  the  average  amount  infected.  In  some  special  classes  of  per- 
sons, such  as  hospital  out-patients,  the  amount  has  approached  five 
per  cent. 

In  the  recruits  entering  the  British  Army  the  percentage  of  car- 
riers has  been  higher  during  the  past  winter  than  during  the  two 
previous  ones.  This  rise  took  place  in  December  and  in  one  garri- 
son at  the  beginning  of  February  fifty  per  cent,  were  found  to  be 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      59 

carriers.  With  this  increase  in  the  number  infected,  an  outbreak 
of  cases  occurred.  The  Research  Committee  conclude  that  when  the 
carrier  rate  is  low,  the  case  rate  is  usually  moderate.  A  rise  in  the 
carrier  rate  is  soon  followed  by  an  increase  in  the  cases.  This  is 
probably  partly  due  to  an  increase  in  the  virulence  of  the  menin- 
gococci. 

Seasons.     The  influence  of  seasons  has  been  already  referred  to. 

The  cases  increased  among  the  troops  in  England  during  Janu- 
ary and  February  and  subsided  in  April.  The  same  general  rise 
and  fall  in  cases  has  been  noted  in  influenza,  measles  and  mumps. 
There  was  not  noted  any  tendency  for  persons  having  these  dis- 
eases to  suffer  in  any  excess  proportion  to  meningitis  but  the  in- 
creased coughing  might  have  had  an  effect  in  spreading  menin- 
gococcic  infection  from  carriers  to  non-infected  persons. 

The  cold  weather,  besides  affecting  the  mucous  membranes,  also 
tends  to  bring  the  troops  in  closer  contact  in  poorly  ventilated  rooms 
and  in  parts  of  the  rooms  not  well  heated  to  allow  a  longer  life 
of  the  meningococci  expelled  into  the  air  in  the  act  of  coughing  and 
talking. 

The  Virulence  and  Types  of  the  Meningococci.  This  attribute, 
except  in  so  far  as  indicated  by  the  severity  of  the  cases,  is  very 
hard  to  measure  as  no  animal  develops  the  disease  naturally  or 
typically.  The  considerable  immunity  of  most  populations  to  the 
common  types  adds  a  difficulty. 

In  England  there  were  found  to  be  in  about  ninety-seven  per  cent, 
of  the  cases,  but  four  strains  of  meningococci.  These,  like  the 
pneumococci,  differed  from  each  other  in  their  immunological  attri- 
butes. The  strain  designated  as  number  2  was  found  to  be  dis- 
tinctly less  in  virulence  for  animals  than  the  others,  but  strains  in 
each  type  differed  among  themselves.  The  great  majority  of  the 
cases  in  England  and  France  were  due  to  the  strains  which  were 
designated  as  1  and  2.  Observations  in  this  country  agree  pretty 
closely  with  those  in  England. 

Means  for  Checking  the  Spread.  1.  The  general  conditions  so 
far  as  sufficient  floor  space  and  ventilation  should  be  made  good. 

2.  Prophylactic  inoculations  of  killed  cultures.  Abroad  in  both 
England  and  France,  these  have  been  given  to  only  a  small  num- 
ber of  persons.  Sophian  of  our  own  laboratories  gave  the  inocu- 
lation to  several  hundred  persons  in  the  Texas  epidemic  of  1912 
with  certainly  no  bad  results.  We  have  recently  inoculated  several 
thousands  of  men  in  our  home  camps.     These  inoculations  should 


60       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

be  thoroughly  tested  out.  The  doses  should  be  of  at  least  the  same 
amount  as  in  typhoid  inoculations.  We  have  used  for  the  three 
doses,  one,  two  and  three  billions.  The  reactions  have  not  been 
severe. 

A  serious  difficulty  is  that  the  different  strains  as  in  the  case  of 
pneumococci  do  not  immunize  efficiently  against  each  other  and  that 
type  one,  in  rabbits  at  least,  does  not  produce  definite  immunity 
against  even  itself.  The  experimental  injections  should  be  made 
partly  with  single  types  and  partly  with  an  equal  mixture  of  all 
types  so  that  the  completeness  of  protection  given,  in  each  case, 
could  be  determined. 

3.     Identification  and  isolation  of  carriers. 

The  English  and  French  have  both  tried  to  separate  the  carriers 
from  the  uninfected  troops  and  the  results  have  been  considered 
good. 

The  English  have  used  these  methods  of  handling  the  carriers. 

A.  Where  cerebrospinal  meningitis  has  occurred  frequently,  all 
the  men  in  the  unit  or  camp  have  been  swabbed  and  the  positive 
cases  removed.  The  general  experience  has  been  that  when  this 
was  done,  the  outbreak  has  stopped.  The  procedure  requires  a  very 
considerable  laboratory  force.  Two  trained  laboratory  men  and 
two  trained  assistants,  if  pushed,  can,  for  a  limited  time,  do  100 
cases  a  day.  All  media,  agglutinating  sera  and  cleaning  are  sup- 
plied  from  a  central  laboratory. 

B.  Swabbing  of  only  those  who  have  been  in  contact  with  the 
cases.  This  is  the  method  generally  adopted  by  both  the  French 
and  English  authorities  for  the  troops,  both  in  the  training  camps 
and  at  the  front. 

The  English  consider,  as  a  possible  contact,  everyone  coming 
within  two  yards  of  the  diseased  person  for  an  appreciable  time. 
If  the  general  carrier  rate  is  low  in  a  camp,  this  procedure  will 
probably  be  quite  effective,  but  if  high,  much  less  so.  It  has  been 
found  that  a  wise  course  is  to  swab  a  considerable  number  of  non- 
contacts  from  the  same  unit  or  camp  and  so  judge  the  general 
proportion  of  carriers  among  non-contacts  as  contrasted  with  con- 
tacts. 

It  has  been  found  that  when  repeated  tests  of  ''non-contacts" 
are  carried  out  that  an  increase  in  carriers  will  be  noticed  in  some 
instances  before  any  cases  occur.  By  this  means,  an  outbreak  may 
be  forecasted  and  prevented. 

C.  The  isolation  and  examination  of  both  those  in  contact  with 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      61 

the  cases  and  those  in  contact  with  positive  contacts.  The  imme- 
diate contacts  are  tested  and  those  proving  positive  are  considered 
as  foci  to  those  who  have  been  in  contact  with  them.  This  method 
is   continued   until   no   more   carriers   are   discovered. 

This  method  was  carried  out  by  the  French  in  a  large  training 
depot.  The  conclusion  was  that  this  method,  while  it  did  not  wholly 
stop  all  further  cases,  yet  it  did  lessen  greatly  the  number. 

The  Research  Committee  believe  that,  if  in  summer,  a  general 
attempt  to  find  the  few  chronic  carriers  could  be  made,  that  the 
winter  spread  of  the  infection  might  be  wholly  or  largely  stopped. 
This  would  mean  a  great  deal  of  work  from  the  bacteriological 
squad — not  only  the  culture  must  be  made  properly,  but  the  culture 
must  be  examined  by  trained  observers. 

Disinfection  of  Carriers.  The  difficulty  of  separating  and  iso- 
lating carriers  suggested  attempts  to  free  cases  from  infection  by 
douches,  sprays  and  vapors.  The  majority  of  carriers  soon  free 
themselves,  but  a  considerable  proportion  remain  injected  for  weeks 
or  months.  A  considerable  proportion  of  these  have  pathological 
anatomical  conditions,  such  as  enlarged  tonsils  and  adenoids,  which 
are  believed  to  favor  the  persistance  of  infection. 

The  longest  duration  of  infection  met  with  was  15 
months. 

Several  different  antiseptic  solutions  were  used  to  make  the  spray. 
The  two  which  seemed  the  most  effective  were  chloramine-T  in 
a  one  to  two  per  cent,  solution  and  zinc  sulphate  in  a  one  per  cent, 
solution. 

The  spray  was  made  by  driving  a  steam  jet  across  the  tube  con- 
necting with  the  solution.  It  was  found  necessary  to  fill  the  cham- 
bers with  a  dense  cloud  of  very  minute  droplets  as  it  was  shown 
that  it  was  the  droplets  themselves  and  not  any  gases  in  the  air 
which  produced  the  effect.  One  litre  of  solution  per  hour  in  a 
room  containing  1000  cubic  feet  gave  about  the  right  density.  The 
carrier  remained  in  the  room  for  ten  to  twenty  minutes  and  inhaled 
vigorously  through  the  nostrils. 

Chronic  carriers  at  least  were  made  to  cleanse  the  nasal  cavity 
with  salt  solution  before  entering  the  chamber.  An  antiseptic 
gargle  such  as  a  one  per  cent.  chloramine-T  or  one  per  cent,  per- 
manganate of  potash  was  considered  of  advantage. 

The  effect  of  the  chloramine-T  treatment  is  to  produce  an  imme- 
diate increase  in  the  flow  of  secretion  from  the  nasopharyngeal 
mucosa.     In  some  cases,  the  mucus  which,  before  the  treatment, 


62       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

contained  numerous  living  meningococci  was  found  to  be  free  on 
leaving  the  chamber. 

In  the  largest  trial  camp,  5,000  men  were  subjected  daily  to  the 
spray  treatment.  In  these  cases  the  one  per  cent,  zinc  sulphate  was 
used  because  it  is  less  irritating  than  the  chloramine. 

The  New  Zealand  and  the  Australian  authorities  used  the  spray 
to  free  "carriers"  going  to  England  on  the  transports.  The  treat- 
ment seemed  not  only  to  free  carriers  but  to  lessen  the  incidence  of 
mumps,  measles  and  colds.  It  seemed  to  diminish  the  chance  of 
infections  which  take  place  through  the  mucous  membranes  of  the 
nasal  cavities,  mouth  and  pharynx.  Fildes  at  the  British  Naval 
Station  at  Portsmouth,  after  a  very  extensive  test,  came  to  the  con- 
clusion that  no  solution  had  much  preference  over  another  and  that 
the  effect  produced  was  not  very  great. 

The  French  have  not  used  the  fine  spray  inhalation  treatment. 
The  meningitis  problem  has  been  far  less  important  in  their  army 
and  the  rigorous  use  of  cultures  to  separate  the  carriers  has  been 
sufficient.  They  believe  swabbing  the  nasopharynx  with  carbolized 
oil  is  of  advantage. 

Dopter  has  tried  the  use  of  insufflations  of  dried  antimeningitis 
serum  and  thinks  they  may  prove  of  value. 

While  it  seems  to  me  impossible  that  the  serum  would  be  effica- 
cious, it  is  worth  investigating  as  it  is  easy  of  application  and  per- 
fectly harmless. 

It  is  apparent  that  while  much  has  been  done  to  lessen  the  spread 
of  meningitis  the  results  are  only  partially  satisfactory  and  further 
investigations  are  necessary. 

Treatment.  The  English  and  French  authorities,  like  ourselves, 
consider  serum  treatment  is  of  great  value.  An  important  point  has 
been  brought  out  that  any  serum,  to  be  efficient,  must  be  potent 
against  the  types  of  meningococci  occurring  in  the  cases  under  treat- 
ment. During  the  first  year  of  the  war,  much  of  the  serum  used 
was  of  little  strength  and  unequal  in  its  potency  for  the  different 
types.     The  results  with  this  serum  were  very  disappointing. 

The  Rockefeller  Institute  and  the  New  York  City  Health  Depart- 
ment have  always  made  certain  that  the  horses  were  treated  with 
balanced  cultures  of  the  different  types  of  meningococci  and  that 
every  lot  of  serum  was  tested  for  its  potency. 

The  United  States  Public  Health  Service  has  just  ruled  that  no 
serum  should  be  sent  out  from  American  producers  until  the  Gov- 
ernment has  assured  itself  of  the  serum's  potency. 


THE  AM  URIC.  IN  CONGRESS  ON  INTERNAL  MEDICINE      63 

Cultures  from  a  number  of  the  European  cases  have  been  brought 
over  to  make  sure  that  those  obtained  by  us  at  an  earlier  time  fully 
cover  the  present  strains. 

Immunisation  against  Typhoid  Fever.  The  greatest  accomplish- 
ment in  the  prevention  of  disease  during  the  war  is  unquestionably 
the  limitation  of  typhoid  and  paratyphoid  fevers  through  vaccina- 
tion. The  military  and  civil  authorities  in  all  countries  are  in  accord 
as  to  this. 

The  results  in  the  French  Army  are  most  striking. 

At  the  beginning  of  the  war,  less  than  half  of  the  troops  had 
been  vaccinated  against  typhoid  fever  and  none  against  paratyphoid 
fever.  During  the  winter  and  spring  of  1915  typhoid  vaccination 
was  pushed,  but  it  was  only  in  the  fall  that  the  paratyphoid  vaccines 
were  commenced. 

The  typhoid  and  paratyphoid  developments  were  as  follows : 

During  the  fall  of  1914  and  the  early  winter  of  1915,  there  were 
many  days  in  which  500  to  700  cases  developed  and  several  thou- 
sand deaths  occurred  each  month.  With  improved  conditions  and 
the  general  use  of  typhoid  vaccines,  the  incidence  gradually  im- 
proved so  that  less  than  100  were  reported.  With  the  hot  weather 
the  cases  increased  somewhat,  so  that  for  a  few  days,  as  many  as 
500  occurred,  but  bacterial  examinations  revealed  that  there  were 
mostly  paratyphoid  fever.  Before  the  summer  of  1916,  the  troops 
had  all  been  vaccinated  against  both  the  typhoid  and  paratyphoid 
A  and  B  bacilli.  The  sanitary  conditions  were  also  better.  The 
combined  result  of  the  vaccination  and  the  better  care  was  that,  at 
the  worst  periods,  less  than  one  per  cent,  of  the  cases  developed  as 
compared  to  1914  and  less  than  ten  per  cent,  of  the  summer  of 
1915.     The  1917  results  were  even  better. 

The  English  from  the  start  vaccinated  all  their  troops  against 
typhoid  fever  and  after  the  first  year  against  the  paratyphoid  fevers. 
The  sanitation  has  always  been  good.  The  combined  effect  has 
been  to  make  typhoid  and  paratyphoid  fever  cases  very  infrequent. 

Dysentery.  The  bacillary  and  amebic  types  of  dysentery  have 
been  moderately  prevalent  in  both  the  French  and  English  armies. 

The  amebic  infection  of  the  English  troops  in  France  occurred 
from  men  transferred  from  Turkey,  and  of  the  French  troops 
through  the  addition  of  men  from  North  Africa. 

The  amebic  form  occurred  during  all  seasons  of  the  year,  while 
the  bacillary  form  occurred  only  in  hot  weather.  At  some  portion 
of  the  front  the  Shiga  infection  was  most  important,  at  others,  due 


64       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

to  the  other  strains.  A  number  of  persons  suffered  simultaneously 
from  both  infections. 

Prevention.  There  is  no  specific  treatment  to  prevent  infection 
in  dysentery.  The  ordinary  precautions  used  against  intestinal  in- 
fections are  employed  as  thoroughly  as  possible.  The  vaccines  so 
far  prepared  from  the  various  strains  of  dysentery  bacilli  have  been 
too  toxic  to  be  much  employed.  The  use  of  specific  serum  and 
bacillus  mixture — sensitized  vaccine — is  still  in  experimental  stage. 

There  have  been  no  vaccines  developed  which  are  effective  in 
developing  immunity  against  infections  due  to  the  ameba. 

Treatment  by  Serum  of  Bacillary  Infection.  The  polyvalent 
serum  from  horses  which  have  been  injected  with  various  types  of 
bacilli  is  used  in  the  treatment  of  severe  cases  in  doses  of  forty  to 
100  c.  c.  It  is  as  a  rule  administered  subcutaneously  every  twelve 
or  twenty-four  hours  for  usually  three  or  four  times.  The  earlier 
it  is  given  the  better.  When  one  type  of  bacilli  is  found  to  be  the 
sole  cause  of  the  local  epidemic,  a  serum  especially  potent  for  this 
type  is  employed  if  it  is  possible  to  obtain  it. 

B.  Amebic  Infection.  Treatment  of  Carriers.  The  usual  treat- 
ment with  emetine  hydrochloride  was  found  to  fail,  in  more  than 
half  of  the  cases,  to  rid  them  of  the  infection.  Lately,  emetin  bis- 
muth iodide  has  been  substituted  by  the  English  with  better  results. 
The  drug  is  given  by  the  mouth  in  doses  of  three  to  four  grains  for 
each  of  twelve  consecutive  days.  In  order  to  prevent  nausea  and 
vomiting,  the  emetin  may  be  given  in  pills  coated  so  as  to  pass  the 
stomach  unaltered.  Diarrhea  and  vomiting  are  thus  less  apt  to 
occur.  Jepps  and  Meakens  report  ten  out  of  eleven  cases  were 
cured  after  twelve  daily  doses. 

Pneumonia.  Lobar  and  broncho-pneumonia  due  to  exposure  or 
as  complication  of  measles  and  other  infections  are  common  both  in 
the  camps  and  in  the  fighting  area.  Lobar  pneumonia  had  been 
epidemic  among  the  Singalese  in  their  camps  in  Southern  France. 

Borrel  showed  me  the  clinical  results  of  the  treatment  of  many  of 
the  cases  with  serum.  In  many  cases,  the  temperature  fell  shortly 
after  its  use.  The  dose  was  fifty  to  100  c.  c.  and  usually  repeated 
once  or  twice.  It  was  given  subcutaneously.  He  had  also  vac- 
cinated all  the  men  in  two  large  camps.  In  one  camp,  the  cases 
became  milder  and  less  frequent  about  ten  days  after  the  second 
inoculation.  In  the  other  camp,  the  course  of  the  epidemic  was 
unchanged.  The  strain  of  pneumococci  used  came  from  a  case  in 
the  first  camp  and  it  is  possible  that  the  type  of  pneumococci  in 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      65 

the  second  camp  are  different.  The  results  in  South  Africa  are 
certainly  very  encouraging  and  I  certainly  feel  that  we  should  test 
out  the  value  in  our  camps  so  that  we  may  soon  have  additional 
knowledge. 

Tetanus.  During  the  early  period  of  the  war  considerable  tetanus 
appeared  among  English  wounded  and  still  more  among  the  French. 
Injections  of  500  units  were  first  made  compulsory  in  all  infected 
wounds  and  then  in  all  wounds.  The  close  of  500  units  was  repeated 
at  the  end  of  several  days  in  all  infected  cases  and  again  when 
thought  necessary. 

Less  than  one  in  1000  now  develop  tetanus  in  the  English  and 
French  Armies,  and  these  rare  cases  are  usually  those  who  re- 
ceived no  antitoxin.  The  serum  in  the  developed  cases  in  France 
is  mostly  given  subcutaneously  or  intravenously  because  of  fear 
of  anaphylactic  shock  if  given  intraspinally  in  cases  who  had  pre- 
viously had  an  immunizing  dose  of  antitoxin.  The  British  advocate 
the  intraspinal  method. 

Trench  Fever.  This  is  a  form  of  relapsing  fever  occurring  espe- 
cially among  the  English  troops  in  Flanders.  The  fever  is  accom- 
panied by  headache  and  pains  in  the  lower  limbs.  The  blood  con- 
tains infectious  organisms  which  do  not  pass  the  stone  filter.  Micro- 
scopical examination  reveals  no  microorganisms.  It  may  be  con- 
veyed by  insects. 


SOME  PROBLEMS  OF  CARDIOVASCULAR  DISEASE 

By  EDWARD  E.  CORNWALL 

Brooklyn,   New   York 

The  central  pump  and  its  tubal  connections,  including  the  kidney 
filters,  may  be  subjected  to  extraordinary  wear  and  tear,  and  the 
pathological  and  functional  manifestations  of  this  wear  and  tear, 
though  variously  distributed  in  locality  and  time,  may  be  brought 
into  one  focus  and  looked  at  as  a  whole ;  and  this  whole  we  call 
cardiovascular  disease.  The  essential  unity  of  cardiovascular  dis- 
ease is  found  in  the  etiology  and  interrelationships  of  its  different 
manifestations;  and  these  make  it  possible  to  consider  it  as  a  clini- 
cal entity  and  to  treat  it  as  such.  It  is  not  synonymous  with  arterio- 
sclerosis,   or    chronic    nephritis,    or   chronic    myocarditis,    although 


66       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

those  are  the  three  principal  pathological  foci  around  which  its 
manifestations  cluster,  so  to  speak. 

Of  the  many  problems  presented  by  this  disease,  only  two  will 
be  discussed  here,  viz.,  its  prophylaxis  and  the  treatment  of  the 
high  blood  pressure  which  is  often  found  associated  with  it. 

The  prophylaxis  of  cardiovascular  disease  is  one  of  the  large 
things  in  preventive  medicine,  and  one  which  deserves  more  atten- 
tion than  it  has  generally  received.  This  disease  occupies  relatively 
as  large  a  place  in  the  morbidity  of  the  latter  half  of  life  as  do  dis- 
eases of  bacterial  origin  in  the  first  half.  Its  prevention  or  post- 
ponement means  much  in  prolongation  of  life  and  usefulness  and 
well  as  saving  of  misery.  The  loss  to  the  world  from  the  shorten- 
ing of  the  period  of  useful  human  activity  caused  by  the  premature 
development  of  this  widespread  disease  is  difficult  to  estimate,  but 
it  looms  large  enough  to  make  its  prophylaxis  a  medical  thing  of 
the  first  magnitude. 

This  prophylaxis  must  take  into  account  the  etiological  factors. 
Among  those  factors  heredity  stands  out  prominently.  The  quality 
of  the  material  of  which  the  cardiovascular  apparatus  is  made  dif- 
fers widely  in  different  individuals,  and  this  quality  is  inheritable. 
One  may  inherit  such  an  apparatus  of  poor  material  just  as  he  may 
inherit  a  constitution  subnormally  resistant  to  tuberculosis.  Hered- 
ity also  admits  other  things  which  bear  on  cardiovascular  disease, 
particularly  conditions  of  metabolic  insufficiency,  which  make  for 
excessive  irritation  and  early  degeneration  of  the  tissues  of  the 
cardiovascular  apparatus,  as  well  as  increased  demands  on  the  elim- 
inative  functions.  Similar  tastes  and  tendencies,  occupations  and 
environments,  moreover,  are  apt  to  be  present  in  successive  gen- 
erations and  to  increase  the  effect  of  heredity.  A  tendency  to  car- 
diovascular disease  can  always  be  suspected  when  the  patient  shows 
a  family  history  of  apoplexy,  nephritis,  diabetes,  obesity,  gout, 
migraine,  chronic  arthritis  or  heart  disease.  It  is  a  matter  of 
strong  probability  that  persons  with  such  a  heredity,  when  they 
come  to  middle  life,  will  begin  to  wear  out  as  to  their  heart,  arteries 
or  kidneys,  if  they  live  as  their  forbears  did,  or  even  if  they  live 
in  the  conventional  way.  This  probability  is  increased  if  they  early 
exhibit  signs  of  symptoms  which  suggest  metabolic  insufficiency, 
such  as  obesity  or  periodical  headaches.  The  so-called  "sick  head- 
aches," occurring  periodically,  are  particularly  suggestive  of  nitro- 
genous metabolic  insufficiency,  and  all  that  implies.  These  people 
if  they  would  escape  their  bad  inheritance  must  adopt  a  mode  of 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      67 

living  which  will  protect  them  as  far  as  possihle  from  the  action 
of  the  other  causative  factors  of  cardiovascular  disease. 

Excessive  work,  physical  and  mental,  is  an  important  factor  in 
the  production  of  this  disease,  and  a  factor  which  usually  can  be 
controlled.  Acute  cardiac  overstrain  may  leave  the  heart  perma- 
nently damaged  or  predisposed  to  degenerative  changes ;  and  long 
continued  physical  overstrain  may  produce  cardiac  hypertrophy, 
arterial  hyperplasia  and  a  predisposition  to  early  degeneration  of 
the  circulatory  apparatus.  Prolonged  mental  work,  the  burden  of 
heavy  responsibilities,  and  worry  long  continued  may  do  the  same 
thing  as  also  may  excessive  indulgence  in  social  dissipations,  late 
hours  and  excitement.  If.  physical,  mental  or  emotional  overstrain 
compel  the  circulatory  apparatus  for  long  periods  to  maintain  an 
average  endarterial  pressure  considerably  higher  than  it  is  accus- 
tomed to,  it  is  easy  to  understand  how  permanent  damage  to  that 
apparatus  can  result. 

A  factor  of  great,  of  not  paramount  importance  in  the  etiology 
of  cardiovascular  disease,  and  one  which  is  to  a  considerable  extent 
under  control,  is  the  excessive,  or  relatively  excessive  burden  which 
is  laid  on  the  circulatory  apparatus  by  the  metabolism  connected 
with  the  processes  of  nutrition.  The  work  of  transforming  material 
from  the  outside  world  into  the  living  tissue  of  the  body  and  avail- 
able fuel,  and  getting  rid  of  the  deleterious  by-products  formed  in 
the  preparation  for  utilization  of  the  food  material,  rests  to  a  large 
extent  on  this  apparatus.  Also,  its  structures  are  subjected  in  the 
meanwhile  to  the  irritating  and  disintegrating  action  of  the  toxic 
by-products  of  an  extensive  chemical  activity. 

The  specific  poisons  of  the  infectious  diseases  also  may  be  causa- 
tive factors  in  the  production  of  cardiovascular  disease.  Syphilis, 
rheumatic  fever  and  typhoid  fever  deserve  special  mention  in  this 
connection. 

Besides  the  toxemic  strain  of  an  unfit  diet  or  a  bacterial  infec- 
tion, a  related  element  in  the  causation  of  cardiovascular  disease, 
and  one  which  usually  can  be  controlled,  it  would  ^eem,  is  chronic 
poisoning  by  alcohol,  tobacco,  coffee  and  lead.  These  poisons  may 
disturb  digestive  operations,  thereby  favoring  the  production  of  in- 
testinal toxins ;  or  the  liver,  thereby  weakening  the  strongest  defense 
of  the  body  against  poisons ;  or  organic  functions  which  directly 
or  indirectly  affect  the  circulatory  apparatus  ;  and  it  is  possible  that 
they  may  themselves  directly  irritate  or  injure  the  cardiovascular 
tissues. 


68       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

In  the  prophylaxis  of  cardiovascular  disease  the  easy  life  and  the 
easy  diet  are  of  the  first  importance,  and  they  are  particularly  nec- 
essary for  those  whose  heredity  marks  them  out  as  probable  victims 
of  the  disease.  The  easy  life  needs  no  special  explanation,  but 
it  may  not  be  amiss  to  say  a  few  words  in  explanation  of  the  easy 
diet. 

The  progress  of  civilization  has  changed  man's  ways  of  life,  in 
many  particulars,  more  rapidly  than  his  organism  could  make  the 
necessary  adjustments ;  and  especially  severe  has  been  the  strain 
of  these  adjustments  on  the  large  part  of  the  population  which  in 
one  or  two  generations  has  made  the  change  from  the  more  natural 
country  life  to  the  more  sedentary  and  exciting  city  life.  Along 
with  the  notable  increase  in  the  proportion  of  our  population  liv- 
ing in  cities  has  been  observed  a  great  increase  in  the  mortality 
from  cardiovascular  disease.  The  conventional  diet,  which  has 
been  developed  not  only  to  meet  the  nutritional  needs  of  the  body, 
but  also  to  gratify  cultivated  and  artificial  tastes,  and  which  is 
largely  a  habit,  remains  now  practically  what  is  was  in  the 
prescientific  period;  and  it  has  no  regard  for  the  easement  of  the 
strain  of  these  adjustments,  but  continues  to  impose  an  unnecessary 
metabolic  burden;  even  if  quantitatively  correct,  it  is  qualitatively 
wrong  in  that  it  admits  regularly  an  unnecessary  amount  of  toxic 
waste  which  the  organism  has  to  get  rid  of.  The  easy  diet  is  reg- 
ulated with  the  object  in  view  of  reducing  to  a  practical  minimum, 
that  is  a  minimum  consistent  with  nutrition  and  comfort,  the  amount 
of  work  which  the  organism  has  to  do  in  feeding  itself  and  fuelling 
itself,  and  clearing  off  the  table  and  cleaning  out  the  furnace.  The 
easy  diet  should  be  regulated  quantitatively,  so  as  to  limit  the 
amount  of  the  various  food  elements  ingested  to  the  reasonable 
needs  of  the  body,  avoiding  on  the  one  hand  luxus  consumption, 
and  on  the  other,  undue  encroachment  on  the  margin  of  nutritional 
safety ;  and  it  should  also  be  regulated  qualitatively. 

Qualitative  regulation  of  the  diet  takes  into  account  the  com- 
position and  qualities  of  various  articles  of  food,  with  special  ref- 
erence to  their  reaction  on  the  human  physiology  after  ingestion. 
Different  articles  of  food  may  have  the  same  proportions  of  the 
various  food  elements,  they  may  have  the  same  amounts  and  kinds 
of  protein  and  the  same  fuel  vlaue,  and  from  the  point  of  view  of 
quantitative  dietetics  be  equivalent;  while  from  the  point  of  view 
of  what  happens  to  them  and  in  consequence  of  them  in  the  body 
they  may  be  far  from  equivalent.     Boiled  spinach  and  boiled  cab- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      69 

bage  may  analyse  about  the  same,  but  from  the  point  of  view  of 
the  easy  diet  they  show  differences.  Dextrose  and  saccharose  may 
supply  the  same  number  of  calories,  weight  for  weight,  but  from 
the  point  of  view  of  qualitative  dietetics  they  have  not  the  same 
physiological  value.  An  ounce  of  lean  beef  and  an  ounce  of  cot- 
tage cheese  contain  about  the  same  amount  of  protein,  with  the 
same  kinds  and  proportions  of  amino  acids,  and  about  the  same  fuel 
value ;  but  they  are  by  no  means  of  equal  value  in  a  prescription 
for  an  easy  diet. 

Perhaps  the  most  important  thing  in  the  matter  of  the  easy  diet 
is  the  selection  of  the  protein  containing  articles,  for  the  burden- 
some and  poisonous  substances  which  are  produced  as  by-products 
in  the  preparation  for  utilization  of  protein  in  the  body  stand  out 
prominently  in  the  etiology  of  cardiovascular  disease ;  and  the 
amount  of  these  poisons  produced  varies  much  in  the  case  of  dif- 
ferent articles.     How  shall  we  make  the  selection  ? 

The  answer  is  found  to  a  large  extent  in  the  fact  that  most  of 
these  toxic  protein  fragments  are  broken  off  from  the  protein  mole- 
cule and  its  derivatives  by  certain  classes  of  bacteria  which  are  reg- 
ularly present  in  the  alimentary  canal ;  and  the  further  fact  that  the 
activity  of  these  bacteria  is  largely  dependant  on  the  chemical  reac- 
tion of  the  media  in  which  they  live;  they  are  particularly  active 
in  an  alkaline  medium,  and  not  so  in  an  acid  one.  These  facts  sug- 
gest that  the  protein  containing  articles  of  food  which  easily  or 
regularly  become  acid  or  stay  so  long  are  the  best  protected  from 
the  action  of  the  protein-poison-splitting  bacteria,  and  are  there- 
fore the  best  suited  to  supply  protein  in  the  easy  diet. 

The  practical  application  is  not  difficult,  for  it  is  a  matter  of  com- 
mon observation  that  some  protein  containing  articles  of  food  easily 
turn  sour  because  of  their  susceptibility  to  the  action  of  harmless 
acid  forming  bacteria,  and  that  some  do  not.  Milk,  bread  and 
cereals  turn  sour  when  they  spoil,  but  animal  flesh  and  eggs  putrefy 
when  they  spoil.  In  fact,  it  is  possible  to  divide  practically  all  the 
articles  of  food  containing  protein  into  two  great  classes,  according 
as  they  turn  sour  or  putrefy  when  they  spoil,  and  the  dividing  line 
runs  very  strictly  between  the  animal  and  vegetable  kingdoms  until 
we  come  to  milk,  which  is  an  animal  food,  but  does  not  putrefy 
but  regularly  sours  when  it  spoils.  This  is  a  fact  of  great  impor- 
tance in  the  matter  of  the  easy  diet,  because  milk  is  an  article  rich 
in  protein,  and  animal  protein,  and  protein  which  contains  all  the 
amino  acids  needed  by  the  body  and  in  approximtaely  the  propor- 


70       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

tions  which  the  hody  can  utilize.  It  also  happens,  as  a  nearly 
universal  rule,  that  the  class  of  protein  containing  articles  which 
sour  when  they  spoil  contain  little  or  no  free  split  proteins  of  the 
undesirable  purin  class,  while  the  contrary  is  the  case  with  animal 
flesh.  The  easy  diet,  then,  considered  from  the  point  of  view  of 
its  protein  ration,  should  be  largely  if  not  altogether  lactovegetarian. 
Yet  it  is  possible  to  say  a  word  in  favor  of  a  small  proportion  of 
animal  flesh  in  the  diet  of  the  average  case.  The  healthy  body  is 
so  accustomed  to  battling  with  these  putrefaction  poisons  that  com- 
plete deprivation  of  them  might  result  in  weakening  of  a  useful 
function.  The  principle  of  variety  also  enters  into  the  question  to 
a  slight  extent,  and  also  the  matter  of  regard  for  habitudes. 

In  this  connection  a  word  about  vegeterianism  may  be  in  place, 
in  order  to  make  clear  the  fact  that  vegeterianism  and  the  easy  diet 
are  in  no  way  synonomous.  A  purely  vegetarian  diet  is  a  hard 
one,  because  of  the  difficulty  of  getting  from  vegetable  articles 
protein  which  contains  the  full  quota  of  amino  acids  needed  by 
the  body,  to  say  nothing  of  getting  them  in  the  ideal  proportions 
which  favor  the  nitrogenous  economy  of  the  body.  Most  of  the 
vegetable  proteins  are  "imperfect  proteins,"  considered  in  relation 
to  the  body  needs,  and  although  it  is  theoretically  possible  to  com- 
bine different  imperfect  proteins  so  as  to  make  them  supplement 
each  other,  there  are  practical  difficulties  in  the  way.  The  easy  diet 
requires  that  a  certain  proportion  of  its  protein  be  derived  from 
animal  sources,  for  the  reason  above  suggested ;  and  it  is  fortunate 
that  of  the  three  classes  of  animal  foods,  viz.,  flesh,  eggs  and  milk, 
there  is  one,  milk,  which  is  particularly  easy  on  every  count ;  and  this 
fact  makes  the  easy  diet  essentially  a  lactovegetarian  one,  which  is 
very  different  from  a  vegetarian  one. 

The  second  of  the  two  problems  connected  with  cardiovascular 
disease  selected  for  discussion  here  is  the  treatment  of  high  blood 
pressure.  High  blood  pressure  is  often  found  associated  with 
cardiovascular  disease,  and  its  treatment  as  a  symptom  sometimes 
comes  into  question.  What  should  be  our  therapeutic  attitude 
toward  this  symptom? 

We  can  no  longer  accept  symptomatic  treatment  as  a  universal 
dogma,  because  symptoms  are  not  essentially  diseases  or  parts  of 
diseases  which  call  for  suppression  or  ablation.  Nor  are  they  al- 
ways or  necessarily  manifestations  of  disease.  On  the  other  hand, 
they  are  often  evidences  of  nature's  counter  operations  to  overcome 
disease,   and   are   physiological   rather   than  pathological   processes. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      71 

Such  seems  to  be  fever,  which,  in  general,  may  be  taken  as  nature's 
constructive  reaction  against  invading  microorganisms  or  their 
toxins.  Even  more  plainly  high  blood  appears  to  be  a  conservative 
physiological  procedure. 

It  may  safely  be  assumed  that  whatever  the  circulatory  apparatus 
does  regularly  is  in  the  interests  of  an  adequate  circulation,  and  high 
blood  pressure  consequently  appears  as  a  manifestation  of  com- 
pensatory activity  to  meet  some  unusual  circulatory  requirement. 
It  may  signify  that  the  organism  is  trying  to  maintain  an  adequate 
circulation  in  the  presence  of  some  obstruction,  or  some  extra  de- 
mand for  elimination :  the  high  pressure  may  be  required  for  the 
benefit  of  a  vital  region  whose  blood  supply  is  impeded  by  arterio- 
sclerosis ;  or  it  may  be  required  for  the  elimination  of  retained 
waste  products  whose  elimination  has  been  rendered  more  difficult 
by  pathological  changes  in  the  kidneys.  With  this  understanding 
of  the  significance  of  high  blood  pressure,  viz.,  that  it  is  physiologi- 
cal instead  of  pathological,  and  regularly  useful  rather  than  harm- 
ful, its  direct  treatment  becomes  restricted  to  the  exceptional  cases 
in  which  nature  has  lost  her  control  over  the  situation  and  is  over- 
doing her  duty  (in  the  presence,  perhaps  of  an  insuperable  obstacle, 
such  as  a  large  blood  clot  pressing  on  the  brain)  ;  as  shown  by 
elevation  of  the  pressure  to  a  point  which  threatens  immediate  in- 
jury to  the  circulatory  apparatus  itself.  In  such  cases  the  use  of 
direct  means  to  lower  the  pressure,  viz.,  the  administration  of  arteri- 
odilators,  may  be  indicated  temporarily.  But  in  general,  the  only 
treatment  of  high  blood  pressure  which  is  rational  is  that  which 
is  directed  toward  removing  or  improving  the  conditions  which 
make  it  necessary ;  and  the  most  important  and  by  far  the  most 
effective  part  of  this  indirect  treatment  consists  in  the  easy  diet. 

THE  ROLE  OF  INFECTION   IN   THE   PRODUCTION   OF 

ADDISONIAN  "SO-CALLED  PERNICIOUS"  ANEMIA 

AND   A    METHOD    OF    TREATMENT    BASED 

UPON  SUCH  CONSIDERATION 

By  FRANK  SMITHIES 
Rochester,   Minn. 

Before  attempt  is  made  to  suggest  treatment  for  an  ailment,  it 
would  appear  quite  essential  first  that  the  nature  of  the  affection 
under  consideration  be  understood  and  second,  that  any  mode  of 


72       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

treatment  advanced  be  directed  toward  the  remedy  of  known  mal- 
functions and  the  local  or  systemic  damage  consequent  upon  such. 
Types  of  therapy  departing  from  these  basic  principles  are  largely 
empiric  and  usually  ephemeral. 

Since  Combes'  original  though  imperfect  description  of  so-called 
pernicious  or  severe  anemia  in  1822  down  to  the  present  time,  the 
nature  of  the  disease  has  been  obscure.  Nevertheless,  numerous 
systems  of  treatment  have  been  advanced  and  have  obtained  a  vogue. 
The  chief  virtue  of  many  of  these  therapeutic  regimes  has  been 
that  the  majority  of  them  were  harmless  to  the  patient — in  many 
instances  the  disease  progressed  in  a  sort  of  self-limited  fashion 
to  a  fatal  termination. 

The  unsatisfactory  status  of  the  treatment  of  so-called  "perni- 
cious" anemia  may  be  ascribed  chiefly  to  the  facts  that  there  has 
been  great  confusion  in  the  medical  mind  as  to  what  group  of  cases 
is  to  be  made  up  of  "pernicious"  anemias  and  what  type  of  case 
is  to  be  excluded  from  the  classification.  Very  likely  the  term 
"pernicious"  taken  in  the  sense  of  "fatal"  is  largely  responsible  for 
some  of  the  existing  confusion. 

The  adoption  of  this  nomenclature  has  resulted  in  the  more  or 
less  general  conception  that  any  anemia  presenting  the  feature  of 
chronicity,  intermittent  and  of  obscure  orgin  should  be  classed  as 
"pernicious."  Moreover,  if  in  a  given  case,  morphologic  study  of 
the  blood  picture  revealed  the  megaloblastic  features  emphasized 
by  Ehrlich,  it  was  presumed  that  the  disease  should  be  included  in 
the  "pernicious"  group.  A  second  and  perhaps  more  important 
cause  for  confusion  arose  as  a  consequence  of  the  carelessly  grouped 
but  widely  circulated  classification  of  the  anemias  by  Biermer  in 
1871.  Although  in  1855,  following  a  masterly  study  of  a  peculiar 
anemia,  Addison  had  clearly  defined  an  unusual  disease  syndrome, 
Biermer,  either  through  lack  of  knowledge  of  Addison's  contribu- 
tion, or  as  a  result  of  his  failing  to  appreciate  the  essential  features 
of  Addison's  anemia,  suggested  the  term  "progressive  pernicious 
anemia"  to  cover  various  forms  of  anemia  both  ideopathic  and 
symptomatic  in  virtue  of  their  having  common  clinical  features. 
Although  Biermen's  classification  was  strenuously  disputed  by 
Eichhorst  and  Immermann,  it  secured  widespread  recognition  and, 
in  fact,  furnished  the  basis  for  Ehrlich's  later  morphologic  classi- 
fication of  the  severe  anemias. 

Before  attempting  to  emphasize  any  mode  of  treatment  of  Addi- 
sonian anemia,  it  is  quite  necessary  that  the  conception  of  the  ail- 


THE  AM  ERIC. IX  COXGRESS  OX  IXTERXAE  MEDICINE      73 

ment  as  described  by  Addison  should  be  appreciated.  It  is  fre- 
quently stated  that  any  severe  anemia  provided  it  is  not  acutely 
fatal  may  result  in  the  clinical  and  morphologic  variations  from 
the  normal  described  by  Addison  ;  that  is,  that  Addisonian  anemia 
and  Biermer's  progressive  pernicious  anemia  are  interchangeable 
terms  which  describe  an  identical  disease  and  that  moreover,  this 
disease  is  not  a  true  clinical  entity  but  represents  a  stage  in  the 
process  of  blood  poverty  from  any  obscure  causes. 

To  anyone  who  has  seriously  compared  the  anemias  clinically 
and  pathologically,  it  becomes  quite  evident  that  the  problem  of 
classification  is  by  no  means  simple.  The  terms  "secondary  anemia" 
(that  is,  due  to  known  or  visible  causes)  and  "primary,"  "essen- 
tial" or  "pernicious"  anemia  (that  is,  anemia  due  to  obscure  causes 
and  usually  resistant  to  treatment), are  not  complete  or  exact.  There 
is  no  sharp  line  separating  the  "secondary"  from  the  "essential" 
anemia  groups.  Under  this  nomenclature:  it  is  common  clinical 
observation  that  not  rarely  one  form  merges  into  the  other.  To  the 
persistent,  acute  and  brilliant  efforts  of  William  Hunter,  we  are  in- 
debted for  calling  attention  to  and  emphasizing  a  most  vital  and 
basic  principle  underlying  the  clinical,  pathologic  and  haemotologic 
features  exhibited  by  the  anemia  described  by  Addison.  Hunter's 
observations,  it  would  seem  definitely  segregate  Addisonian  anemia 
from  the  great  group  of  severest  anemias  previously  named  generi- 
cally,  primary,  essential,  ideopathic  or  pernicious.  Based  upon  his 
classification  I  have  grouped  the  anemias  etiologically  as  follows: 

THE  SEVERE  ANEMIAS 

(1)  .So-called  "Secondary  Anemias" 
Mild  i      Malnutrition 

or  -:      Hemorrhage 

Severe  |      Post  Infectious  (acute) 

(2)  So-called  "Primary  Anemias"  Morphologically 

(a)   Chronic  Septic  or  Toxic.      (Non-Jiacniolytic)  L 

Syphilis 

Tuberculosis 

Kala— Azar  Many 

Trvpanosomiasis  )  „ 

T    ' '         ,     ,,  /    Organisms 

Low  grade  Sepses 

Bothriocephalus 

Etc. 


&■ 


I  Many 
/  Toxin 


74       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Chlorosis 
Carcinoma 
Nephritis 
Cirrhosis 
Diabetes 
Lead 

Toluendiamine 
Disordered  Endo- 
crine Function 

(b)    SPECIFIC,  Chronic  Septic  with  Constant  or  Intermittent 
Hacmoh'tic  Features. 


ADDISONIAN    ANEMIA 

"Progressive,  Pernicious  Anemia."  A  disease  in  which  constant 
clinical  and  pathologic  changes  are  associated  with  an  anemia  which 
may  be  mimicked  by  that  of  other  forms  of  severe  enemia. 

After  twenty-five  years  of  patient  endeavor,  and  work  not  gen- 
erally directly  appreciated,  Hunter's  views  are  in  the  main  definitely 
substantiated  by  modern  clinical  investigation  and  the  anemia  of 
Addison  segregated  as  a  special  form  of  anemia  with  a  specific 
probably,  group  etiology.  It  would  seem  to  be  now  possible  to 
define  Addisonian  anemia  as  essentially  a  hacmolytic  anemia.  It 
would  seem  that  further,  it  is  a  specific,  chronic  anemia  whose  con- 
stant or  intermittent  haemolytic  features  are  closely  associated  with 
sepsis  or  the  consequences  of  such.  This  septic  agent  is  generally 
intermittently  active,  extends  over  comparatively  long  periods  of 
time  and  is  associated  with  organisms  or  agents  of  the  haemolytic 
group.  Such  organisms  or  toxins  invade  tissue,  are  widely  dis- 
seminated in  the  body,  but  probably  have  a  special  affinity  for  lym- 
phoid tissue  and  their  toxins  a  special  destructive  action  upon 
lymphoid  tissue.  Such  organisms  are  described  variously  as 
"streptococcus  longus"  (Hunter),  "streptococcus  viridans,"  "lytic 
staphylococci"  and  bacilli  stimulating  those  of  the  colon  group.  It 
is  quite  essential  that  these  facts  emphasized  by  William  Hunter  in 
his  septic  theory  should  be  appreciated.  It  is  likewise  necessary 
that  the  evidences  of  hemolysis  in  Addisonian  anemia  by  recent 
investigators  be  recognized.  These  observations  are  basic  as  aids 
to  the  segregation  of  the  type  of  anemia  under  consideration. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      75 
CHARACTERISTICS  OF  THE  DISEASE 

A  brief  review  of  the  essential  clinical  features  of  the  ailment 
would  appear  to  be  opportune.  The  disease  may  be  (a)  chronic, 
or  (b)  acute. 

(a)  Chronic  Addisonian  Anemia.  This  form  of  the  disease  is 
most  frequently  encountered.  Clinically,  it  is  not  possible  to  im- 
prove upon  the  classic  description  of  the  ailment  presented  by 
Thomas  Addison  in  1855.  It  is  as  follows :  "For  a  long  period  I  had 
from  time  to  time  met  with  a  very  remarkable  form  of  general 
anemia  occurring  without  any  discoverable  cause  whatever — cases 
in  which  there  had  been  no  previous  loss  of  blood,  no  exhausting 
diarrhea,  no  chlorosis,  no  purpura,  no  renal  splenic  miasmatic, 
glandular,  strumous,  or  malignant  disease.  Accordingly,  in  speak- 
ing of  this  form  in  clinical  lectures,  I,  perhaps  with  little  propriety, 
applied  to  it  the  term  "ideopathic,"  to  distinguish  it  from  cases  in 
which  there  existed  more  or  less  evidence  of  some  of  the  usual 
causes,  or  concomitants  of,  the  anemic  state. 

The  disease  presented,  in  every  instance,  the  same  general  char- 
acter, pursued  a  similar  course,  and,  with  scarcely  a  single  excep- 
tion, was  followed,  after  a  variable  period,  by  the  same  result. 

It  occurs  in  both  sexes,  generally,  but  not  exclusively,  beyond  the 
middle  period  of  life ;  and  so  far  as  I  at  present  know,  chiefly  in 
persons  of  a  somewhat  large  and  bulky  frame,  and  with  a  strongly 
marked  tendency  to  the   formation  of   fat. 

It  makes  its  approach  in  so  slow  and  insidious  a  manner  that  the 
patient  can  hardly  fix  a  date  to  his  earliest  feeling  of  that  languor 
which  is  shortly  to  become  extreme. 

The  countenance  gets  pale,  the  whites  of  the  eyes  become  pearly, 
the  general  frame  flabby  rather  than  wasted  ;  the  pulse  perhaps  large, 
but  remarkably  soft  and  compressible,  and  occasionally  with  a  slight 
jerk,  especially  under  the  slightest  excitement.  There  is  an  increas- 
ing indisposition  to  exertion,  with  an  uncomfortable  feeling  of 
faintness  or  breathlessness  on  attempting  it ;  the  heart  is  readily 
made  to  palpitate ;  the  whole  surface  of  the  body  presents  a 
blanched,  smooth  and  waxy  appearance ;  the  lips,  gums  and  tongue 
seem  bloodless ;  the  flabbiness  of  the  solids  increases ;  the  appetite 
fails  ;  extreme  languor  and  faintness  supervene,  breathlessness  and 
palpitation  being  produced  by  the  most  trifling  exertion  of  emotion  ; 
some  slight  edema  is  probably  perceived  about  the  ankles.  The 
debility  becomes  extreme ;  the  patient  can  no  longer  rise  from  his 


76      THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

bed ;  the  mind  occasionally  wanders ;  he  falls  into  a  prostrate  and 
half-torpid  state,  and  at  length  expires.  Nevertheless,  to  the  very- 
last,  and  after  a  sickness  of  perhaps  several  months  (or  years) 
duration,  the  bulkiness  of  the  general  frame  and  the  obesity  often 
present  a  most  striking  contrast  to  the  failure  and  exhaustion  ob- 
servable in  every  other  respect. 

With  perhaps  a  single  exception,  the  disease,  in  my  own  expe- 
rience, resisted  all  remedial  efforts  and  sooner  or  later  terminated 
fatally.  On  examining  the  bodies  of  such  patients,  after  death,  I 
have  failed  to  discover  any  organic  lesion  that  could  properly  or 
reasonably  be  assigned  as  an  adequate  cause  of  such  serious  con- 
sequences ;  nevertheless,  from  the  disease  having  uniformly  oc- 
curred in  fat  people,  I  was  naturally  led  to  entertain  a  suspicion 
that  some  form  of  fatty  degeneration  might  have  a  share  at  least  in 
its  production ;  and  I  may  observe  that,  in  the  case  last  examined, 
the  heart  had  undergone  such  a  change,  and  that  a  portion  of  the 
semilunar  ganglion  and  solar  plexus  on  being  subjected  to  micro- 
scopic examination  was  pronounced  by  Mr.  Quekett  to  have  passed 
into  a  corresponding  condition. 

Whether  any  or  all  of  these  morbid  changes  are  essentialy  con- 
cerned— as  I  believe  they  are — in  giving  rise  to  this  very  remark- 
able disease,  future  observation  will  probably  decide." 

Clinically  to  Addison's  description  may  be  added  gastric  achylia 
without  stagnation,  diminished  pancreatic  ferment  secretion,  fre- 
quent or  intermittent  exhausting  diarrhea,  continuous  or  intermit- 
tent albuminuria,  spinal  cord  changes  usually  of  the  spastic  type, 
disturbances  in  sensation  particularly  malfunction  of  the  special 
senses  and  not  rarely  psychic  upsets. 

(b)  Acute  Type  of  Addisonian  Anemia.  This  occurs  infre- 
quently. In  107  cases  observed  by  me,  it  was  present  but  five 
times.  The  following  history  emphasizes  some  of  the  clinical 
aspects  of  the  acute  form  of  the  affection. 

On  January  12,  1916,  there  was  brought  to  our  clinic  upon  a 
stretcher  a  semi-conscious  female  aged  35.  At  the  time  of  entry  she 
exhibited  low  muttering  delirium,  lemon  yellow,  waxy,  oily  skin, 
pale,  water  logged  mucus  surfaces,  extreme  weakness  and  dyspnoea. 
The  general  body  nourishment  was  moderately  well  preserved.  The 
hemoglobin  was  eighteen  per  cent.,  the  red  cell  count  920.000,  the 
leucocyte  count  2,300.  The  stained  blood  smear  showed  a  large 
celled  anemia,  marked  poikilocytosis  and  polychromatophilia  and 
numerous  normoblasts  with  an  occasional  megaloblast.     The  lym- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      77 

phocytes  were  fifty-six  per  cent,  of  the  total  differential  count;  the 
coagulation  time  was  more  than  eight  minutes. 

The  previous  history  of  this  patient  is  interesting.  Up  to  Octo- 
ber, 1915— three  months  before  coming  under  observation,  the 
patient  was  and  had  been  in  perfect  health.  So  excellent  had  her 
health  been  that  she  was  considered  somewhat  as  a  prize  beauty 
in  her  county.  In  early  October,  she  was  affected  with  a  form  of 
sore  throat  with  grippe-like  sequelae,  which  lasted  for  about  ten 
days  and  left  her  much  exhausted.  The  exhaustion  continued,  a 
lemon  color  pallor  became  noticeable,  a  swelling  appeared  below  the 
edge  of  the  left  ribs,  irregular  temperature  was  recorded  and  five 
weeks  following  the  initial  illness  a  blood  examination  revealed  the 
quantitative  and  morphologic  picture  associated  with  Addisonian 
anemia.  The  patient  was  removed  to  a  hospital  in  one  of  the  large 
cities  of  Iowa  and  a  standard  form  of  treatment  instituted  by  a 
very  competent  internist.  The  patient  made  practically  no  prog- 
ress. Anorexia,  diarrhea,  dyspnea,  palpitation  of  the  heart  and 
mental  changes  became  established.  The  swelling  below  the  rib 
edge  was  proven  to  be  the  spleen,  it  persisted  and  increased  and 
became  so  painful  that  deep  breathing,  lying  on  the  left  side  or 
palpation  caused  exquisite  distress.  The  blood  pictured  showed 
no  change  except  quantitatively  the  hemoglobin  and  red  cell  mass 
slowly  and  steadily  diminished. 

In  this  striking  picture,  I  would  emphasize  particularly  the  acute 
onset  of  the  ailment  in  a  previously  well  individual,  the  disease 
being  initiated  by  a  sore  throat ;  the  rapidly  developing  anemia  in 
every  respect  that  of  a  pernicious  or  Addisonian  anemia;  the  clini- 
cal appearance  of  the  patient  which  in  the  space  of  a  few  months  be- 
came that  which  is  commonly  associated  with  Addisonian  anemia  of 
long  standing;  the  rapid  and  persistent  enlargement  of  the  spleen  so 
painful  as  to  be  described  by  the  patient  herself  as  feeling  like  a 
"large  boil."  Further  examination  showed  this  case  to  be  non- 
syphilitic.  A  haemolytic  coccus  was  isolated  from  the  throat  and  a 
similar  organism  from  the  tissue  of  the  gall  bladder  and  the  spleen. 
This  case  will  be  considered  in  detail  with  regard  to  treatment  later. 

BLOOD  FINDINGS  IN  ADDISONIAN  ANEMIA 

Emphasis  is  to  be  placed  upon  the  statement  that  the  blood 
morphology  set  down  by  early  investigators  as  indicating  essen- 
tial or  ideopathic  anemia  or  Addisonian  anemia  may  be  closely 
mimicked  in  numerous  forms  of  anemia  where  the  cause  is  known 


78       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

or  evident  and  that  upon  blood  morphology  alone  or  even  upon 
quantitative  blood  studies  alone,  absolute  diagnosis  of  the  disease 
is  not  possible.  The  blood  studies  are  only  to  be  taken  when  con- 
sidered with  respect  to  the  clinical  course  of  the  disease  and  pos- 
sible with  regard  to  evidences  of  haemolysis. 

Usually  there  are  shown  a  low  erythrocyte  count  (fifteen-fifty 
per  cent,  of  normal),  the  average  being  1,200,000  (Cabot)  while 
Quinke's  case  of  143,000  holds  the  record  for  low  counts.  The 
hemoglobin  is  decreased,  but  in  lesser  degree  than  the  red  blood 
cell  count,  thus  making  the  color  index  greater  than  one  in  the 
majority  of  cases. 

The  fragility  of  the  erythrocytes  is  increased.  The  platelets  are 
diminished,  often  absent.  The  normal  is  500,000  (J.  H.  Pratt), 
while  in  pernicious  anemia  they  usually  are  less  than  100,000  per 
cu.  m.m.  The  stained  smear  shows  nucleated  red  blood  corpuscles 
and  multitudes  of  large  and  small,  misshapen  and  contorted  red 
blood  cells.  Cells  measuring  from  two  to  twenty  microns  in  diam- 
eter (microcytes  and  marcrocytes),  "dumbbells,"  "doughnuts," 
"pears,"  "commas,"  "ovals,"  "pseudopods"  and  "rings"  (poikilo- 
cytes)  are  common.  Nucleated  red  blood  corpuscles  are  frequently 
present  at  some  stage  of  the  ailment.  They  vary  in  size  and  are 
designated  microblasts,  normoblasts  and  megaloblasts,  accordingly. 
Cells  containing  Howells  nuclear  particles  are  often  seen.  These 
various  blast  cells  represent  the  reserve  currency  of  the  bone  mar- 
row and  indicate  that  the  demand  for  erythrocytes  is  so  imperative 
that  the  marrow,  being  unable  to  produce  matured  cells,  throws 
off  their  parent  form — the  erythroblasts.  The  degree  of  the  mar- 
row's embarrassment  is  probably  indicated  by  the  type  of  blast 
found  in  the  circulating  blood,  the  more  primitive  the  nucleated 
cell,  the  more  urgent  the  systemic  call  for  red  corpuscles.  In  very 
severe  cases,  however,  no  nucleated  cells  many  be  seen.  This  prob- 
ably indicates  almost  complete  marrow  exhaustion. 

Besides  nucleation,  the  circulating  red  blood  corpuscles  show 
polychromatophilia,  reticulation,  Ehrlick's  "spotting,"  vacuolation 
and  rarely  basophilic  degeneration. 

There  is  a  marked  leukopenia,  usually  about  3,500,  although 
counts  as  low  as  330  and  as  high  as  13,000  have  been  reported. 
Higher  leucocyte  counts  are  rare.  They  probably  are  associated 
with  active  infection  or  the  free  absorption  of  toxic  agents  which 
temporarily  stimulate  the  defenisve  mechanism  in  the  blood  making 
centers.     Evidence  suggestive  of  this  is  adduced  from  the  prompt 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      79 

leucocytosis  following  blood  transfusion  with  or  without  associated 
splenectomy. 

The  leucocytes  are  of  smaller  size  than  normal,  myelocytes  more 
numerous  and  often  basophilic  granules  are  seen  in  the  cytoplasm. 
The  differential  counts  usually  show  an  increase  in  the  small  lympho- 
cytes and  a  decrease  in  the  polymorphonuclear  percentages — in 
fact,  the  normal  percentages  are  often  reversed,  so  that  lympho- 
cytes outnumber  polymorphonuclears  three  to  one.  Such  reversal 
of  the  normal  differential  leucocyte  ration  might  be  interpreted  as 
indicating  diminution  of  the  blood's  defensive  mechanism. 

CHANGES    IN    THE   BLOOD   PLASMA 

Coagulation  time  is  prolonged,  but  not  so  greatly  as  in  hemophilia 
and  icterus.  Our  cases  ranged  from  three  to  ten  minutes.  The 
appearance  of  the  blood  is  watery,  milky  or  greasy,  and  sometimes 
it  is  nearly  impossible  to  smear  it  evenly  on  a  slide.  Ehrlich  de- 
scribes the  flow  from  a  puncture  wound  as  "streaked."  The  volume 
of  erythrocytes,  as  determined  by  the  hematocrit  of  Oliver,  is  les- 
sened out  of  proportion  to  the  serum,  which  is  often  pinkish  in 
color  from  the  free  hemoglobin.  The  specific  gravity  of  the  serum, 
freed  from  corpuscles,  is  nearer  normal. 

Nayen  and  LeNoble  say  that  the  fibrin  is  decreased  and  that  the 
clot  in  pernicious  anemia  does  not  retract  even  after  seventy-two 
hours.  Other  observers  do  not  agree  to  this  statement.  We  have 
noticed  that  the  clot  is  soft  and  insecure,  and  is  easily  dislodged. 

Blankenhorn  has  recently  demonstrated  an  increase  in  the  bile 
pigment  in  the  blood  in  cases  of  Addisonian  anemia.  There  would 
also  seem  to  be  variations  in  the  cholestrin  and  iodine  factors.  It 
has  not  been  constantly  shown  that  the  lytic  bodies  are  increased. 
In  certain  cases  it  has  been  shown  by  Eppinger  and  by  King  that 
the  blood  serum  contains  an  increase  in  the  unsaturated  fatty  acids 
in  the  blood  some  of  which  have  been  shown  to  be  highly  lytic. 

PATHOLOGIC  ALTERATIONS 

General.  The  most  striking  feature  of  the  disease  is  the  general 
fatty  degeneration  of  the  systemic  non-striated  and  heart  muscula- 
ture and  of  the  liver,  kidneys  and  bone  marrow.  All  the  body  tis- 
sues are  hydraemic  except  the  spleen  which  is  commonly  firm  and 
congested.     Multiple  small  hemorrhages  into  meninges,  brain,  spinal 


80       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE  ■ 

cord  and  retina  are  not  uncommon.  Such  lesions  are,  however, 
not  especially  specific  of  Addisonian  anemia.  The  researches  of 
Hunter  and  others  would,  however,  indicate  that  in  Addisonian 
anemia  there  are  specific  changes  which  have  been  commonly  over- 
looked by  many  observers. 

Hunter  lays  particular  emphasis  upon  the  lesions  in  the  mouth. 
It  is  a  common  observation  that  in  many  forms  of  severe  anemia 
infected  gums,  tonsils  and  nasal  accessory  sinuses  are  coincident. 
Not  infrequently  the  infecting  organisms  are  haemolytic  cocci  or 
bacteria.  Decayed,  broken  teeth  are  very  generally  noted.  Hunter 
emphasizes  the  importance  of  these  long  persisting  infections  with 
respect  to  a  peculiar  glossitis  which  he  claims  is  quite  characteristic 
for  Addisonian  anemia.  We,  ourselves,  have  noticed  the  tongue 
changes  as  being  practically  constant  in  haemolytic  anemias  of 
Addisonian  type,  in  fact,  we  have  never  seen  a  true  case  of  Addi- 
sonian anemia  in  which  the  tongue  did  not  show  varying  degrees 
of  atrophy  of  the  mucous  membrane  and  hyperplasia  of  the  muscles 
of  the  tongue.  Hunter  claims  that  there  is  no  other  anemia  in 
which  the  glossitis  is  so  constant  and  persistent.  He  claims  that 
the  glossitis  fluctuates  in  severity  as  does  the  disease  and  that  the 
preence  of  the  glossitis  accounts  for  the  alterations  in  the  special 
senses  particularly  of  taste  so  characteristic  of  the  disease.  Hunter 
has  shown  that  while  in  many  severe  anemias,  superficial  inflam- 
matory changes  of  the  tongue  are  quite  common,  in  Addisonian 
anemia  there  is  an  actual  invasion  of  the  lymph  spaces  and  muscle 
bundles  of  the  tongue  with  lytic  streptococci.  Hunter  claims  that 
the  tongue  furnished  the  most  important  portal  of  entrance  for 
these  bacteria  or  their  toxins  into  the  general  circulation.  Tissue 
cultures  from  the  tongue  would  apparently  show  these  organisms 
in  pure  culture.  Pathologic  changes  similar  to  those  observed  in 
the  tongue  have  been  observed  in  the  stomach  wall  and  that  of  the 
large  intestine.  In  the  early  course  of  the  disease,  the  gastroin- 
testinal lesions  are  of  the  ulcerative  type,  later  inflammatory 
action  results  in  a  scar  tissue  with  atrophy  of  the  mucosa  and  mus- 
cularis.  Haemolytic  bacteria  can  often  be  isolated  from  the  walls 
of  both  stomach  and  intestine,  upon  tissue  culture  after  the  technic 
of  Rosenow. 

In  our  clinic,  tissue  cultures  have  been  made  of  removed  appen- 
dices and  gall  bladders.  While  grossly  all  these  appendicies  and  gall 
bladders  show  chronic  inflammatory  changes  with  or  without  evi- 
dences of  ulceration,  in  some  of  the  specimens,  streptococcus  veri- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      81 

dans,  lytic  staphlococci  and  organism  of  the  colon  group  have  been 
recovered. 

Besides  fatty  change  and  frequent  enlargement,  the  liver  presents 
a  rather  characteristic  picture  with  respect  to  the  distribution  of  iron 
pigment.  The  deposits  of  iron  pigment  are  increased  from  six  to 
ten  times  the  normal  amount.  This  increased  iron  is  characteris- 
tically deposited  in  the  outer  and  middle  zones  of  the  lobules.  This 
increase  of  iron  pigment  does  not  occur  as  result  of  iron  medication 
nor  does  it  occur  in  secondary  anemias  to  such  extent  nor  in  such 
position.  By  Charnas  and  Schneider's  methods  for  the  estimation 
of  blood  derived  pigments,  duodenal  catheterized  fluid  appears 
characteristically  to  reveal  a  great  increase  in  the  elimination  of  uro- 
bolin  and  urobilinigen  by  the  liver.  In  only  the  lytic  anemias  is  this 
great  increase  in  blood  derived  pigments  constantly  found.  This 
observation  is  of  value  in  separating  instances  of  true  Addisonian 
anemia  from  anemia  where  the  blood  morphology  indicates  a  severe 
anemia  often  carelessly  called  "Addisonian." 

Examination  of  the  kidneys  in  pernicious  anemia  shows  increased 
iron  deposits.  In  the  urine  are  demonstrated  increased  urobiligen 
and  hetero-  and  perhaps  iso-hemolysins. 

BONE    MARROW 

Smears  of  the  bone  marrow  reveal  in  the  early  stages  of  perni- 
cious anemia  megaloblastic  hyperplasia  in  the  majority  instances. 
This  is  apt  to  be  succeeded  by  aplasia  which  represents  an  over- 
work or  fatigue.  In  certain  cases  of  Addisonian  anemia  aplasia 
may  be  early  manifested.  Bone  marrow  cultures  have  not  been 
made  in  sufficient  number  of  cases  of  Addisonian  anemia  to  enable 
one  to  state  definitely  whether  or  not  there  is  actual  bone  marrow 
infection  but  evidence  is  accumulating  which  offers  to  substantiate 
this  opinion.  It  would  appear  that  the  bone  marrow  changes  may 
represent  reactions  to  the  haemolytic  agent.  It  would  seem  in 
Addisonian  anemia  the  bone  marrow  is  not  primarily  at  fault.  In- 
jections with  pure  cultures  of  staphylococcus  pyogenes  aureus 
cause  definite  bone  marrow  reactions  closely  resembling  the  megalo- 
blastic reactions  produced  in  Addisonian  anemia.  Following  the  in- 
jection of  non-bacterial  hemolytic  agents  as  has  been  described  by- 
Bunting  similar  changes  are  observed.  It  is  quite  likely  that  in 
Addisonian  anemia,  widespread  infection  with  hemolytic  cocci  re- 
tards blood  formation. 


82       THE  AMERICAS  CONGRESS  OX  INTERNAL  MEDIC IX E 

SPLEEN 

Spleens  removed  at  laparotomy  from  cases  of  Addisonian  anemia 
in  our  clinic  almost  universally  show  increase  in  size,  blood  conges- 
tion, chronic  peri-splenitis  and  often  increase  in  weight.  On  section- 
ing the  tissue  evidences  chronic  hyperplasia.  The  iron  content  is 
greatly  decreased.  In  some  instances  of  Addisonian  anemia  tissue 
cultures  from  the  spleen  pulp  have  returned  hemolytic  cocci  and 
colon-like  bacilli.  Spleen  extracts  have  not  exhibited  increased  iso- 
or  hetero-haemolysins. 

It  might  be  well  to  review  certain  functions  performed  by  the 
spleen.  Even  though  the  exact  use  of  the  spleen  is  unknown,  it 
would  appear  from  its  embryology  to  be  an  important  organ  con- 
cerned with  digestion  or  assimilation  of  food.  It  will  be  recalled 
the  blood  supply  of  the  spleen  comes  from  the  coelio  axis  as  does 
that  of  the  stomach,  liver  and  pancreas.  The  spleen  is  derived  from 
the  fore  gut  as  are  also  these  organs.  Its  venous  efterents  are 
direct  tributaries  to  the  portal  circulation.  The  chief  functions  of 
the  spleen  would  appear  to  be  those  connected  with  control  of  blood 
formation  and  with  blood  destruction.  In  the  human  embryo 
erythrocytes  are  produced  by  the  spleen  but  at  birth  this  produc- 
tion ceases  and  the  bone  marrow  becomes  practically  the  sole  course 
of  the  red  blood  cells.  The  spleen  is,  however,  intimately  con- 
cerned with  the  production  of  leucocytes.  Kolliker  and  Ebener 
found  more  leucocytes  in  the  splenic  vein  than  in  the  splenic  artery. 
The  large  mononuclears  (splenocytes)  formed  in  the  spleen  prob- 
ably do  not  enter  the  blood  stream  but  remain  and  serve  as  partial 
sources  of  haemolysis.  There  is  reason  to  believe  that  even  nor- 
mally the  spleen  exercises  a  certain  degree  of  inhibition  upon  the 
bone  marrow,  influencing  the  formation  and  the  addition  to  the 
circulation  of  both  red  and  white  cells.  Lethaus,  Kuttner,  Roetner 
and  Lagg  have  noted  polycythenia  following  removal  of  the  spleen 
traumatically  ruptured.  Schupfer,  Levison  and  Muhsan  and  Mayo 
have  similarly  noted  increased  red  cells  following  splenectomy  in 
Banti's  disease.  The  tremendous  medullary  reaction  after  splenec- 
tomy in  pernicious  anemia  has  been  commonly  noted.  Sometimes 
the  pain  in  the  long  bones  following  the  operation  is  definitely  asso- 
ciated with  this  increased  medullary  activity. 

That  the  spleen  bears  a  direct  relation  to  iron  metabolism  has 
been  abundantly  proven  by  the  work  of  Ascher  and  his  pupils,  by 
Schmidt,  Voegel  and  Baer.     It  seems  probable  that  the  spleen  is  a 


THE  AMERICAN  COXGRESS  OX  INTERNAL  MEDICINE      83 

depot  for  iron  derived  from  destruction  of  blood  and  tissue  cells 
The  liver  stores  the  iron  coming  to  the  body  in  food.  After  splenec- 
tomy Baer  has  shown  a  marked  reduction  in  hemoglobin  when 
animals  receive  but  little  iron  in  the  food  and  rapid  improvement 
when  iron  is  added.  Pearce  has  emphasized  that  the  iron  in  un- 
cooked food,  particularly  unboiled  food  is  of  greater  benefit  after 
splenectomy  than  that  in  cooked  or  boiled  food  and  from  this  ob- 
servation thinks  that  the  spleen  is  in  some  way  concerned  with  the 
process  of  indigestion.  Increased  siderosis  may  be  an  indication, 
therefore,  of  general  tissue  cell  destruction.  Increase  of  iron  bear- 
ing pigment  in  the  liver  and  kidneys  is,  on  the  other  hand,  charac- 
teristic of  active  haemolytic  processes  and  especially  of  active 
haemolysis  in  the  spleen.  Just  what  function  the  spleen  has  in 
digestion  is  not  known.  It  may  have  some  influence  with  respect  to 
stomach  and  liver  hyperemia.  It  does  not  seem  to  be  directly  con- 
cerned with  the  proper  elaboration  of  pepsin  and  trypsin.  Certainly 
after  removal  of  the  spleen  in  Addisonian  anemia,  Banti's  disease, 
etc.,  there  is  a  tremendous  improvement  in  appetite,  less  gastric  dis- 
tress and  frequently  of  vomiting.  The  relation  of  the  spleen  to  the 
ductless  glands  and  the  haemolymph  nodes  is  still  undetermined. 
Certainly  after  splenectomy,  enlargement  of  the  thymus,  thyroid 
and  haemolymph  node  is  not  uncommon.  Such  have  been  noted 
by  Tizonni,  Mosler,  Warthin  and  Dock,  Pearce  and  Austin  and 
others.  The  latter  observers  have  shown  that  after  splenectomy  in 
dogs  there  is  a  great  increase  of  the  endothelial  cells  in  the  lymph- 
nodes  and  have  found  that  these  cells  may  become  phagocytic  for 
erythrocytes  following  the  injection  of  haemolytic  serum.  Eppinger 
has  pointed  out  that  the  failure  of  splenectomy  to  benefit  certain 
cases  of  pernicious  anemia  may  be  referred  to  the  increased  hemo- 
lytic activity  of  many  newly  formed  hemolymph  glands. 

The  relation  of  the  spleen  to  infectious  disease  has  been  fre- 
quently commented  upon.  It  has  been  generally  supposed  that  the 
spleen  acts  as  a  powrer  for  good  in  the  struggle  against  infections. 
There  is  no  evidence  to  show-  that  immune  bodies  are  more  favor- 
ably developed  in  the  spleen  than  they  are  in  other  organs.  Patients 
without  spleens  have  not  rarely  been  shown  to  survive  from  severe 
infectious  disease.  It  may  be  that  in  such  circumstances  the  hemo- 
lymph nodes  take  on  the  function  of  the  spleen.  The  relation  of 
the  spleen  to  neoplasms  is  worthy  of  notice,  primary  cancer  of  the 
spleen  is  extremely  uncommon.  The  injection  of  spleen  emulsion 
into  rats  has  been  shown  by  Osser  and  Pribam  to  be  followed  by 


84       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

retrogressive  changes  in  rat  tumors.  Murphy  has  shown  that  rat 
sarcoma  will  grow  freely  in  chick  embryos  only  before  the  develop- 
ment of  the  spleen.  Carroll  has  found  that  connective  tissue  growth 
is  greatly  activated  by  extract  of  adult  spleen.  Eppinger  on  the 
other  hand  has  shown  that  the  removal  of  the  spleen  in  man  may 
be  followed  by  greatly  accelerated  tumor  growth. 

The  Relation  of  the  Spleen  to  Hemolysis.  Under  normal  con- 
ditions there  is  maintained  a  delicate  balance  between  blood  de- 
struction and  blood  production.  The  bone  marrow  reacts  sensi- 
tively to  increased  carbondioxide  tension  of  the  blood  to  the  prod- 
ucts of  red  blood  destruction  and  to  many  chemical  and  infective 
agents.  It  is  not  to  be  doubted  that  normally  the  spleen  prevents 
entrance  into  the  blood  stream  of  materials  which  would  stimulate 
excessive  bone  marrow  activity.  Normally  there  is  little,  if  any, 
active  destruction  of  red  blood  cells  in  the  general  circulation. 
Their  slow  destruction  is  brought  about  mainly  by  the  spleen  al- 
though there  is  some  haemolysis  in  the  liver  and  bone  marrow. 
The  spleen  causes  red  cell  destruction  by  autolysis  and  by  phagocy- 
tosis. The  iron  of  the  blood  cells  is  deposited  as  an  albuminate 
of  iron  mainly  in  the  spleen  and  is  used  later  in  the  formation  of 
new  red  blood  cells  and  hemoglobin.  In  the  absence  of  the  spleen, 
Gilbert,  Chabrole  and  Benard  have  demonstrated  that  the  liver  may 
transform  hemoglobin  into  bile  or  bile  pigment. 

In  Addisonian  anemia,  numerous  authors  notably  Kelliger,  Benti, 
Minkowski,  Hunter  and  Chauffard  and  Eppinger  assign  a  very 
active  role  in  the  hemolysis  to  the  spleen.  They  maintain  that  in 
this  disease,  there  is  a  definite  hypersplenism  and  that  the  red  blood 
cells  are  destroyed  far  in  excess  of  their  rate  of  manufacture  by 
the  bone  marrow.  Other  observers  as  Ponfick,  Goodall  and  Achard 
maintain  that  the  spleen  is  increased  in  size  in  pernicious  anemia 
as  the  consequence  of  the  excessive  quantity  of  products  of  blood 
destruction  brought  to  it.  It  is  also  maintained  that  a  combination 
of  the  two  views  is  possible,  namely,  that  blood  destruction  may  be' 
primarily  initiated  elsewhere  than  in  the  spleen  and  that  as  a  con- 
sequence of  the  toxic  products  brought  to  it  the  spleen  responds 
with  an  overwork  hyperplasia  with  the  resultant  over-normal  hem- 
olysis. Under  such  circumstances  it  is  apparently  evident  that 
removal  of  the  spleen  in  an  ailment  such  as  Addisonian  anemia  can- 
not cure  the  disease  unless  the  primary  haemolytic  fault  is  eradi- 
cated. 

Effects  of  Splenectomy.     In  our  clinic,  Percy  has  observed  that 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      85 

immediately  after  splenectomy  a  polymorphonuclear  leucocytosis 
generally  appears,  due  probably  to  necrosis  of  tissue  following 
operation,  being  a  chemotactic,  phagocytic  reaction.  The  nucleated 
red  blood  corpuscles  become  more  numerous  at  first,  especially 
Howell's  cells,  after  which  they  gradually  disappear  from  the  cir- 
culation. 

After  a  slight  fall  following  the  operation,  the  red  blood  count 
and  hemoglobin  steadily  rise.  The  stomach  symptoms  are  im- 
proved, and  there  is  a  decided  gain  in  weight  and  strength.  In  some 
patients  a  sensitiveness  of  the  long  bones  is  present.  The  red  cells 
tend  to  lose  their  misshapen  condition  and  become  more  uniform  in 
size.  Lee,  Vincent  and  Robertson  say  that  products  of  red  blood 
corpuscles  destruction  (i.  e.,  bile  pigments)  decrease  in  the  excreta 
— the  cells  become  more  resistant  to  hypotonic  salt  solutions.  Plate- 
lets appear  or  increase  in  numbers — the  color-index  falls  to  approxi- 
mately one,  and  the  normal  ration  between  polymorphonuclears 
and  small  lymphocytes  is  gradually  established  after  the  initial 
polymorphonuclear  leucocytosis  declines.  The  abnormal  blood  cells 
generally  disappear  in  from  six  to  twelve,  weeks. 

The  Problem.  From  the  above  clinical  review  of  the  work  of 
others  and  ourselves,  it  would  appear  that  the  problem  of  treatment 
embraces  certain  fundamental  principles.  It  would  seem  that  in 
the  proper  treatment  of  true  Addisonian  anemia  the  clinical  and 
therapeutic  treatment  indicated  includes  the  (a)  attempt  to  bring 
the  patient's  blood  serum  within  the  biologic  normal  by  such  pro- 
cedure as  diluting  or  antagonizing  lysins  and  supplying  and  stimu- 
lating the  production  of  specific  protective  anti-bodies;  (b)  the 
attempt  to  remove  radically  active  foci  containing  lytic  bacteria  or 
to  counteract  the  constant  or  intermittent  absorption  of  their  toxins 
or  their  spread  to  new  localities  ;  (c)  the  attempt  to  simulate  normal 
red  cell  production  in  the  bone  marrow  or  to  temporarily  substitute 
an  adequate  number  of  normal  red  blood  cells  until  bone  marrow 
damage  is  repaired;  (d)  the  attempt  to  improve  the  patient's  gen- 
eral state  by  stimulating  or  supplying  normal  alimentary  secretions, 
preventing  the  absorption  of  injurious  end  digestion  products  from 
the  digestive  tract,  stimulating  the  circulatory  mechanism  and  the 
excretory  function  of  the  liver,  kidneys  and  surface  glands;  (e) 
to  attempt  the  protection  of  newly  formed  and  old  red  blood  cells 
in  selected  cases  by  removal  of  the  hyperlytic  spleen  and  intra- 
abdominal infected  tissue. 


86       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

TREATMENT 

(a)  The  attempt  to  bring  the  patient's  blood  serum  within  the 
biologic  normal.  Instances  have  been  not  infrequently  reported 
where  there  was  rapid  improvement  in  the  qualitative  and  quantita- 
tive analysis  of  the  blood  following  saline  transfusion  or  copious 
lavage  of  the  gastro-intestinal  canal  with  normal  salt  solution.  In 
these  instances,  doubtless  the  improvement  resulted  from  the  dilu- 
tion of  inimical  agents  in  the  blood  stream.  It  would  appear  more 
physiologic  to  bring  about  such  change  by  such  procedure  as  trans- 
fusing all  or  part  of  the  constituents  of  normal  blood.  We  have 
used  transfusion  with  whole  blood  (uncitrated  and  undiluted)  be- 
cause it  seems  more  rational  to  add  nothing  to  transfused  blood  nor 
take  anything  from  it  (as  by  the  citration  of  blood  or  its  defibrina- 
tion). In  all  instances  we  have  found  the  Percy  modification  of 
the  Kimpton-Brown  method  a  practical  and  useful  clinical  proced- 
ure. Donors  have  been  selected  by  the  method  advocated  by 
Walter  Brem.  In  our  cases,  the  average  number  of  transfusions 
were  3.5  given  at  six  to  ten  day  intervals  and  the  average  amount 
of  each  transfusion  was  appioximately  650  cc.  Not  rarely,  the 
patient  requires  transfusions  even  after  laparotomy.  We  have 
found  transfusions  the  quickest  and  most  satisfactory  wray  of  coun- 
teracting relapses  and  stimulating  general  metabolism. 

(b)  The  attempt  to  counteract  the  effects  of  low  grade  infection. 
While  the  patient  is  being  transfused  (at  intervals),  search  for  local 
infective  foci  is  carefully  made.  Radiographic,  cultural  and  physi- 
cal evidences  of  such  are  commonly  found  in  tonsils,  about  teeth 
roots,  in  the  sinuses  accessory  to  the  nose  and  occasionally  in  the 
ear  or  in  superficial  lymph  gland  change.  When  such  have  been 
located,  they  are  radically  removed  as  far  as  is  practical.  Par- 
ticular attention  is  paid  to  the  removal  of  infections  about  the  mouth 
or  throat  where,  in  this  type  of  ailment,  they  appear  to  be  particu- 
larly common.  As  we  have  above  mentioned,  emphasis  has  been 
placed  upon  this  condition  by  William  Hunter.  Our  cases  strongly 
substantiate  many  of  Hunter's  observations.  The  improvement  in 
general  well  being  and  the  character  of  the  blood  have  not  infre- 
quently been  very  prompt  and  marked. 

(c)  The  attempt  to  stimulate  normal  red  cell  production  includes 
frequent  massive  transfusions  as  well  as  attention  to  the  general 
body  demands.  It  has  frequently  seemed  to  us  that  the  chief  func- 
tion of  transfusion  appeared  to  be  that  of  supplying  blood  function 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      87 

physiologically  and  giving  the  bone  marrow  an  opportunity  to  re- 
cuperate. It  has  seemed  not  unlikely  that  the-  circulation  of  good 
blood  in  the  bone  marrow  locally  destroyed  harmful  agents  and 
later  on  permitted  a  bone  marrow  blood  production  of  increased 
vigor  and  approaching  normal  in  quality. 

(d)  The  attempt  to  improve  the  patient's  general  state.  Many 
of  our  cases  of  Addisonian  anemia  exhibit  evidences  of  general 
under  nourishment  either  chronic  or  intermittent.  It  is  not  suffi- 
cient that  enough  food  be  taken  but  it  is  necessary  that  a  proper 
amount  of  food  be  absorbed  into  the  lymph  or  blood  stream.  All 
of  our  cases  have  exhibited  gastric  achylia  with  good  motility.  By 
clinical  and  laboratory  tests,  pancreatic  achylia  especially  for  pro- 
teins and  fats  has  been  demonstrated.  Quantitatively  the  bile  has 
been  normal  or  is  increased  in  amount  but  qualitatively  there  have 
been  such  departures  from  the  normal  as  excesses  of  blood  derived 
pigments  and  possibly  such  agents  as  stimulate  pancreatic  flow  or 
the  production  of  duodenal  or  jejunal  secretions.  Dietetically  we 
have,  therefore,  suggested  a  diet  limited  with  respect  to  proteins  and 
fats.  The  digestive  function  has  been  improved  by  the  use  of  hydro- 
chloric or  tartaric  acid  following  meals  and  frequent  doses  of  calo- 
mel not  for  the  purpose  of  moving  the  bowels  but  with  the  object 
of  bringing  about  a  relative  sterility  of  the  intestinal  canal.  In  a 
few  instances,  various  preparations  of  enzymes  have  been  admin- 
istered along  with  large  doses  of  calcium  carbonate  but  apart  from 
the  diminution  in  the  volume  of  the  stool,  we  have  not  noticed  that 
their  value  has  been  great.  The  renal  activity  has  been  stimulated 
by  the  free  ingestion  of  pleasant  table  waters  or  by  distilled  water 
and  the  cardiac  mechanism  generally  responded  satisfactorily  to 
rest,  massage,  frequent  baths,  caffein  and  digitalis.  It  is  impor- 
tant to  keep  patients  affected  with  this  ailment  at  rest  in  bed  espe- 
cially during  the  periods  of  transfusion.  There  is  no  objection  to 
their  being  out-doors  in  all  kinds  of  weather,  provided  they  are 
properly  protected  from  sunburn  or  extreme  degree  of  cold. 

(e)  The  attempt  to  protect  newly  formed  and  old  red  blood  cells 
by  surgical  procedure.  Inasmuch  as  in  certain  instances  of  Addi- 
sonian anemia  it  appears  that  intra-abdominal  foci  of  infection 
exist  and  that  there  is  increased  blood  destruction  by  the  spleen 
and  the  hemolymph  nodes,  certain  cases  that  were  in  fair  physical 
shape,  whose  blood  picture,  could  not  be  kept  improved  by  trans- 
fusion, removal  of  superficial  foci  of  infection,  diet,  etc. ;  and  in 
whom  there  were  not  evidences  of  extensive  or  progressive  cerebral 


88       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

spinal  damage,  have  submitted  to  a  laparotomy.  Such  laparotomy 
should  always  be  exploratory  in  the  fullest  sense  of  the  word.  Not 
infrequently,  the  surgical  operation  of  splenectomy  is  performed 
but  only  rarely  does  laparotomy  reveal  that  the  spleen  alone  is 
diseased.  In  only  three  of  twenty-seven  consecutive  instances  was 
splenectomy  alone  performed.  In  twenty  cases,  the  spleen,  gall 
bladder  and  appendix  were  removed,  in  three  cases  the  spleen  and 
gall  bladder  and  in  two  others,  the  spleen  and  appendix.  Tissue  cul- 
tures from  the  gall  bladders  and  appendixes  removed,  as  has  been 
mentioned  above,  not  rarely  disclosed  active  infections  with  lytic 
cocci  or  bacilli  of  the  colon  group.  Such  organisms  have  also  been 
isolated  from  removed  ovaries  and  tubes. 

Dr.  R.  W.  Wilcox  :  It  is  a  little  dangerous  for  a  speaker  to 
quote  Holy  Writ  because  another  quotation  may  be  found  to  refute 
the  first.  I  believe  that  there  was  one  individual  in  the  Bible  who 
was  supposed  to  have  subsisted  seven  years  on  a  vegetarian  diet, 
that  is,  on  grass.  Nebuchadnezzar  was  the  name  of  this  person. 
I  am  very  much  interested  in  the  question  of  vegeterianism.  Very 
few  persons  are  absolutely  strict  vegetarians,  although  they  claim 
to  be.  I  know  of  one  man,  a  physician,  who  was  a  fairly  strict 
vegetarian,  and  it  is  remarkable  to  note  in  this  connection  that  the 
more  nearly  a  person  approaches  a  non-animal  diet,  the  more  sweets 
he  is  apt  to  consume.  They  are  also  likely  to  be  inordinate  users 
of  tobacco.  So-called  vegetarians  often  consume  a  considerable 
number  of  eggs  in  their  diet.  In  Europe  one  often  finds  vegetarian 
restaurants,  but  the  only  palatable  article  they  seem  to  offer  is  a 
really  delicious  chocolate,  and  this  seems  to  be  the  only  excuse  one 
would  have  for  wishing  to  patronize  such  an  institution.  I  would 
like  very  much  to  express  my  appreciation  of  Dr.  Cornwall's  schol- 
arly presentation  of  this  subject  and  I  hope  that  the  response  of  the 
members  by  discussion  will  be  generous. 

Dr.  Field:  Mr.  Chairman,  I  consider  this  subject  to  be  one  of 
tremendous  importance.  We  should  all,  as  internists,  appreciate 
Dr.  Cornwall's  scholarly  presentation  of  this  matter.  In  my  own 
work,  I  am  the  director  of  the  radium  institute  in  New  York  City, 
my  attention  is  constantly  called  to  the  study  of  patients  in  this 
condition.  Cancer  cases,  of  course  come  to  us  for  treatment,  and 
in  ninety-five  per  cent,  of  the  cases  they  have  received  every  other 
kind  of  treatment  first.     The  Germans  have  written  for  the  past  ten 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      89 

years  on  the  value  of  radium  in  internal  treatment,  and  the  cases 
sent  to  us,  are  where  diet,  where  all  known  treatments  have  failed. 
Many  cases  come  to  us  running  a  blood  pressure  of  from  180-240, 
with  extreme  kidney  or  heart  lesions  or  both.  It  can  here  be  stated 
that  if  any  result  in  these  cases  is  obtained  from  the  administration 
of  radium,  it  comes  from  the  action  of  the  rays  on  the  body  meta- 
bolism, that  is  the  body  ferments.  Even  with  the  most  minute  dose 
of  radium  water,  there  is  an  enormous  increase  of  solids  in  the 
urine,  with  corresponding  vascular  dilatation.  It  is  certainly  true, 
as  Dr.  Cornwall  says,  that  the  pressure  should  be  slowly  and  grad- 
ually brought  down,  but  where  one  can  bring  about  an  improvement 
in  the  action  of  the  kidneys,  dilatation  is  a  safe  procedure.  The 
patient  may  have  been  on  an  extremely  restricted  diet  for  six  years 
and  yet  the  blood  pressure  can  be  brought  down  thirty  points. 
These  results  show  a  fair  degree  of  permanence.  I  have  noted 
continuance  of  results  after  3l/>  years.  The  importance  of  these 
conclusions  is  enormous.  The  number  of  business  men  who  are 
going  down  every  day  with  cardiovascular  disease  is  appalling. 
The  first  symptoms  of  degeneration  of  the  cardiovascular  system 
must  be  studied.  As  Dr.  Cornwall  has  stated,  if  one  can  head  off 
the  first  beginning  of  degeneration,  the  changes  in  the  valves  be- 
fore disturbance  starts  in  the  blood  vessels,  then  the  profession  has 
in  its  hands  one  of  the  most  important  phases  of  internal  medicine 
that  it  has  ever  had  to  deal  with. 

Dr.  Tice  :  It  would  seem  at  the  present  time  that  the  question 
of  diet  is  of  the  utmost  importance  in  dealing  with  cardiovascular 
disease,  and  this,  in  turn,  is  closely  bound  up  with  the  question  of 
tonus,  or  cardiac  power.  Diet  plays  a  large  part,  both  in  the  pro- 
duction of  disease  and  also  in  the  restoration  of  cardiac  efficiency. 
A  very  important  thing  is  the  reserve  power  of  the  heart  and  its 
ability  to  return  to  its  tonus.  The  question  that  concerns  the  profes- 
sion is  not  so  much  whether  the  actual  involvement  is  myocardial  or 
aortic,  what  is  the  functional  ability  still  possessed  by  the  heart. 
This  again  hinges,  not  only  upon  the  question  of  actual  change 
and  vascular  capacity,  but  also  whether  or  not  the  heart  is  receiving 
its  proper  amount  of  nutrition.  Whether  this  is  to  be  corrected  by 
regulation  of  diet ;  or  to  attention  to  other  metabolic  disturbance,  by 
increase  of  elimination;  by  radium  therapy;  mechanical  therapy; 
or  any  other  we  may  use ;  the  whole  thing  rests  upon  the  re-estab- 
lishment of  cardiac  tonus,  which  practically  means  cardiac  function. 


90       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Dr.  R.  W.  Wilcox  :  I  would  like  to  suggest  a  correction  to  the 
first  speaker.  He  mentioned  cardiovascular  dilatation ;  I  am  sure 
he  meant  "vascular  dilatation."  How  does  radium  act  ?  So  far  as 
I  know  but  little  reliable  research  has  been  undertaken  and  the 
results  of  it  are  by  no  means  conclusive  in  supporting  the  claims 
made  by  chemical  officers. 

Dr.  Baar,  Portland,  Oregon:  The  first  thing  radium  does  is  to 
cause  leucocytosis.  Whether  this  increased  leucocytosis  has  any- 
thing to  do  with  increased  metabolism,  and  thereby  elimination  of 
toxins  and  consequent  prevention  of  arteriosclerosis  is,  as  yet,  a 
purely  speculative  question.  When  we  ask  if  radium  stimulates 
enzymes  and  hormones  we  are  surely  as  yet  dealing  with  abstract 
metaphysics.  So  far  as  we  know  now  there  is  leucocytosis  and 
nothing  else.  Internists  must  stick  to  their  ground.  Leucocytosis 
is  as  much  of  a  conundrum  now  as  it  was  2,000  years  ago.  We  can't 
say  anything  new  about  it. 

Dr.  Barach  :  I  would  like  to  touch  upon  one  or  two  important 
points.  For  the  last  twelve  or  fifteen  years  I  have  been  specially 
interested  in  the  subject  of  cardiac  hypertrophy.  I  would  like  to 
bring  to  your  minds  that  efforts  at  cardiac  compensation  occur 
frequently  in  adolescent  boys,  and  youth  of  college  age.  We  do 
not  have  the  opportunity  to  study  girls  at  this  age  so  much,  but 
in  boys,  it  is  perhaps  the  result  of  increased  muscular  activity. 
Ofter  in  these  subjects,  up  to  and  during  the  college  age,  we  find 
the  apex  is  prominent  and  there  is  an  increased  area  of  dulness, 
although  we  do  not  state  that  a  boy  has  an  hypertrophied  heart 
because  the  dulness  goes  beyond  the  average.  This  may  be  only 
functional,  and  not  pathological.  I  have  an  opportunity  to  see  many 
college  boys  and  in  the  Carnegie  technical  schools  from  three  to 
five  thousand  are  examined  every  year  and  frequently  there  is  a 
condition  of  cardiac  hypertrophy.  In  regard  to  athletics,  the  men 
who  train  for  the  Marathon  race  of  twenty-five  miles  are  in  train- 
ing several  months  of  the  year.  These  men  show  increased  blood 
pressure  and  enlarged  hearts  on  physical  examination.  In  these 
cases  there  is  a  true  hypertrophy.  Shortly  after  the  maximal  effort, 
many  of  them  show  broader  hearts  with  symptoms  of  dilatation. 
Within  a  few  weeks  many  of  these  hearts  return  to  the  normal 
size,  so  that  as  soon  as  there  is  relief  of  the  excessive  strain  the  con- 
dition disappears.  This  shows  that  the  hypertrophy  is  in  response 
to  the  demand  of  the  organism.     I  know  of  one  man  who  came  to 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      91 

me  and  for  fifteen  wars  he  had  been  in  the  practice  of  keeping  in 
training  to  run  twenty-five  miles,  for  no  other  reason  that  that  he 
thought  he  was  smart  for  doing  it.  This  man  had  a  permanent 
hypertrophy  of  the  heart.  Another  thing  that  is  apt  to  happen  when 
these  college  boys  run  five,  ten  or  fifteen  miles,  the  most  of  them 
come  back  showing  signs  of  albumin,  red  blood  cells  and  even 
casts  in  the  urine.  This  condition  can  be  produced  within  five 
minutes  after  commencement  Of  the  effort.  It  is  not  surprising 
that  casts  can  be  thus  produced,  by  excessive  effort  for  a  few 
minutes,  but  the  point  to  be  borne  in  mind  in  connection  with  this 
sign  is  that  an  albuminuria  may  be  very  transient  and  when  a 
patient  conies  mto  the  office  with  this  symptom,  it  does  not  neces- 
sarily follow  that  it  is  a  serious  condition.  The  history  of  medicine 
after  the  Civil  War  shows  that  there  are  many  cases  of  damaged 
hearts.  We  wonder  if  there  will  be  any  interesting  and  startling 
results  recorded  now  in  the  army  as  many  men  who  have  lived 
sedentary  lives  will  be  obliged  to  undertake  long  marches.  It  is 
probable  that  many  of  these  will  show  enlarged  hearts  and  many 
latent  weaknesses  will  be  developed.  There  is  a  class  of  cases 
which  come  in  the  hypertension  class.  These  patients  exhibit  all 
the  symptoms  of  hyperthroidism.  They  have  the  nervous  sym- 
tomatology,  sugar  in  the  urine  and  exophthalmos,  associated  with 
hypertension.  After  ten  days  or  so  of  treatment  by  rest  in  bed  a 
remarkable  change  is  brought  about  in  the  nervous  condition.  They 
no  longer  show  signs  of  the  "excessive  kinetic  drive"  of  Crile. 
This  class  of  patient  is  remarkably  amenable  to  treatment  and  break- 
ing the  vicious  circle  will  produce  a  remarkable  improvement  in 
the  state  of  hypertension.  During  the  past  few  years  I  have  noticed 
several  patients  of  the  large,  obese  type,  having  a  low  blood  pressure, 
110  systolic,  they  also  had  albumin  and  casts  in  the  urine.  These 
cases  have  rapidly,  that  is  within  a  year,  progressed  to  the  stage 
of  hypertension,  160-180  systolic  pressure,  which  shows  how  quickly 
the  hypertension  may  develop.  These  symptoms  are  apt  to  have 
their  beginning  in  early  college  days,  but  in  middle  life  they  develop 
very  rapidly. 

Dr.  Baar  :  YVe  may  have  some  very  interesting  speculative  ideas 
in  regard  to  this  matter.  I  have  not  seen  this  matter  published 
anywhere,  of  which  I  am  going  to  speak.  A  year  ago  I  noticed  a 
man  of  seventy  years  of  age,  who  had  had  a  prostatectomy  done. 
He  had  a  pressure  of   140.     A  week  after  he  left  the  hospital   I 


92       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

took  the  blood  pressure  and  found  it  to  be  240,  but  he  had  no  sub- 
jective symptoms  at  all,  no  albumin,  no  casts,  absolutely  nothing 
pathological.  I  treated  this  man  with  prostatic  tablets  and  the  pres- 
sure dropped  to  170  and  stayed  so.  I  wish  to  mention  this  for  the 
sake  of  priority,  not  because  we  can  prove  any  definite  connection 
in  this  case. 

Dr.  A.  Caille  :  I  would  like  to  express  my  appreciation  of  Dr. 
Cornwall's  presentation.  He  has  approached  the  subject  from  a 
point  of  view  that  makes  us  think  that  we  are  at  last  getting  away 
from  "tinkering."  A  slight  improvement  in  nomenclature  might  be 
suggested ;  I  would  prefer  to  say  cardiovascular  diathesis,  instead 
of  cardiovascular  disease;  that,  however,  is  a  minor  point.  As  to 
the  importance  of  a  restricted  diet,  I  fully  agree  with  the  speaker. 
A  carbohydrate  diet  with  milk  derivatives  is  indicated  in  these  con- 
ditions. I  would  like  to  say  a  word  about  high  blood  pressure.  I 
think  Dr.  Cornwall  mentioned  that  the  adjustment  of  diet  and  vaso- 
dilators are  indicated.  That  is  true.  I  have  found  also  that  a  vene- 
section, done  two  or  three  times  a  year  will  carry  these  patients  on 
for  many  years  and  can  be  of  considerable  comfort  without  much 
trouble. 

Dr.  Ives  :  I  merely  wish  to  discuss  this  paper  from  the  stand- 
point of  food  and  metabolism.  I  think  when  we  go  into  the  ques- 
tion of  amino-acids,  we  are  somewhat  out  of  our  depth.  Speaking 
in  terms  of  eggs,  meat  and  milk,  we  can  work  our  conclusions  out 
clinically.  It  must  be  remembered  that  not  all  of  these  patients 
with  cardiovascular  disease  are  adults,  and  therefore  it  is  not  al- 
ways a  case  of  faulty  metabolism  and  high  pressure.  Some  of  the 
problems  have  to  be  considered  from  the  point  of  view  of  toxemia. 
There  is  always  some  damage  to  the  cardiovascular  tract  in  in- 
fectious disease.  The  doctor  spoke  of  rest ;  rest  becomes  an  im- 
perative factor  for  a  much  longer  time  than  the  period  of  illness. 
From  the  standpoint  of  high  pressure,  mention  has  been  made  of 
prostatic  tablets.  In  senility  it  is  to  be  remarked  that  there  is  often 
a  low  pressure,  a  hypo-tension.  With  these  patients,  one  should 
advise  a  course  of  thyroid  or  pituitrin  and  they  may  respond  beauti- 
fully in  their  pressure  curve.  This  shows  that  there  is  something 
depressive  in  the  lack  of  internal  secretion,  even  with  cardiovas- 
cular disease.  A  course  of  thyroid  or  pituitrin  will  restore  the 
patient  to  normal  health. 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      93 

Dr.  Heinricii  Stern  :  The  alimentary  tract  of  the  occidental 
human  being  is  not  fitted  to  elaborate  completely  the  vegetable  nutri- 
ents or  their  contents.  We  must  not  forget  that  in  the  oriental 
races,  such  as  the  Japanese,  a  much  smaller  race — the  alimentary 
tract  is  from  three  to  six  feet  longer  than  in  the  European.  This 
extra  three  to  six  feet  undoubtedly  serves  some  special  purpose 
in  metabolism.  According  to  experiments  made  in  Tokio  there  is 
no  diet  more  suitable  to  the  Japanese  than  the  one  they  are  best  fit- 
ted to  elaborate.  They  do  well  with  carbohydrates.  I  understand 
that  they  don't  use  milk  at  all,  nor  do  they  make  use  of  milk  deriva- 
tives, including  butter  and  cheese. 

Dr.  R.  W.  Wilcox  :  The  Chair  was  interested  in  the  reference 
to  "tinkering"  in  medicine.  I  would  like  to  refer  to  the  use  of  the 
sphygmomanometer  in  clinical  medicine.  In  1300  men,  veterans 
of  the  Civil  War,  the  majority  having  reached  the  age  of  seventy, 
a  very  frequent  sign  that  was  observed  was  an  extremely  low  blood 
pressure.  At  the  same  time  there  were  great  variety  of  serious 
forms  of  heart  disease.  It  is  unnecessary  in  a  society  of  this  scien- 
tific prominence  to  observe  that  the  sphygmomanometer  is  of  no 
more  and  no  less  use  or  importance  than  other  instruments  of  preci- 
sion, for  example,  the  clinical  thermomter.  High  or  low  pressure  is 
not  to  be  considered  per  se.  It  merely  affords  all  opportunity  for  in- 
vestigating as  to  the  cause  thereof.  We  hope  that  the  object  of  this 
organization  will  be  to  stop  "tinkering"  and  get  to  the  bottom  of 
things.  This  paper  of  Dr.  Cornwall's  shows  that  we  are  fulfilling 
our  mission  as  internists. 

Dr.  E.  E.  Cornwall  :  There  are  very  many  interesting  points 
which  have  been  brought  out  by  the  discussion.  In  the  first  place, 
as  to  the  name  cardiovascular  disease.  It  is,  I  admit,  a  clumsy 
name,  but  it  does  mean  a  wearing  out,  a  clinical  syndrome.  Other 
names  are  much  better  perhaps ;  cardiovascular-renalism  would  be 
a  better  term,  but  we  have  become  accustomed  to  the  other  and  we 
understand  it  to  express  the  general  syndrome.  As  to  Dr.  Baar's 
remark  about  our  having  learned  nothing  in  2000  years  about  leuco- 
cytosis,  I  don't  quite  agree  with  him.  We  have  learned  the  name, 
at  least.  In  regard  to  the  use  of  dilators — anything  like  the  use  of 
dilators  is  absolutely  wrong  in  the  majority  of  cases.  We  must 
understand  that  these  symptoms  are  a  manifestation  on  the  part 
of  nature  that  she  is  trying  to  compensate  the  damage.  It  is  when 
nature  overdoes  her  part  and  injury  is  threatened  to  the  vascular 


94       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

structure — then,  and  then  only,  have  we  any  right  to  use  the  artifi- 
cial methods  of  relief  and  to  save  the  rest  of  the  organism  at  the 
expense  of  the  mechanism.  I  think  the  use  of  dilators  is  a  great 
deal  overdone.  As  regards  venesection — that  is  a  mighty  good 
thine  to  do  sometimes.  It  has  saved  life  many  a  time.  When 
there  is  a  low  diastolic  pressure  an  arterial  dilator  should  never 
be  used.  In  regard  to  amino-acids,  which  have  been  spoken  of  in 
a  somewhat  slighting  tone,  amino-acids  are  the  end  products  in  the 
digestion  of  protein.  The  vegetable  proteins  are  not  as  conveniently 
used  in  body  metabolism  as  animal  protein.  As  to  vegetarians, 
those  who  eat  eggs  or  milk  are  not  strict  vegetarians.  In  regard  to 
the  length  of  the  alimentary  tract,  no  doubt  a  shorter  alimentary 
tract  requires  a  little  meat,  but  the  tendency  to-day  is  to  eat  too  much. 
A  certain  amount  of  meat  is  useful.  A  person  born  with  a  constitu- 
tional predisposition  to  gout,  apoplexy,  Bright's  disease  or  cardio- 
vascular disease  should  i  ike  a  low  animal  protein  diet.  The  phe- 
nomenon of  low  blood  pressure  being  seen  in  old  persons  is  not 
unusual.  It  is  frequently  seen  and  such  persons  are  often  compar- 
atively healthy  and  get  along  very  well.  There  are  some  common 
factors  which  may  produce  this  symptom.  The  first  is  chronic 
tobacco  poisoning.  This  will  lower  the  systolic  pressure.  Second, 
an  intestinal  toxemia  will  sometimes  lower  the  blood  pressure, 
though  this  depends  on  the  type  of  bacterial  poison.  A  colon  bacillus 
toxemia  will  raise  the  blood  pressure,  at  least  it  does  so  in  animal 
experimentation.    Thirdly  might  be  mentioned  a  constitutional  habit. 

Dp..  R.  W.  Wilcox  :  There  is  one  clinical  symptom  which  these 
patients  present,  which  is  noted  by  Addison  and  which  has  not 
escaped  the  observant  eye  of  Dr.  Smithies ;  namely  mental  deteriora- 
tion. This  does  not  proceed  pari-passu  with  the  blood  picture.  It 
is,  however,  a  matter  of  great  importance  occasionally  as  it  may 
occur  in  the  course  of  a  judicial  inquiry.  This  is  a  wonderful  paper 
and  invites  extended  discussion.  There  are  many  points  in  it  which 
have  not  been  enlarged  upon  owing  to  lack  of  time.  One  point 
that  might  be  justly  called  "tinkering"  was  treatment  of  this  disease 
by  splenectomy  per  sc. 

Dr.  Barach  :  I  believe  this  is  one  of  the  first  indications  we  have 
had  that  we  are  getting  down  to  the  underlying  cause  in  pernicious 
anemia.  We  have  been  wandering  in  a  maze  without  knowing 
where  to  go.     Now  we  see  that  infection  is  a  very  likely  source  of 


THE  AMERICAN  CONGRESS  OX  INTERNAL  MEDICINE      95 

the  trouble.  It  has  been  lately  recognized  that  infection  round  the 
mouth  is  a  probable  source  of  much  trouble.  Efforts  have  been 
directed  toward  the  removal  of  pyorrhea  which  is  a  frequent  accom- 
paniment in  these  cases.  The  picture  of  the  tongue  in  pernicious 
anemia  is  characteristic — the  red,  beefy,  smooth,  cracked  tongue 
is  prominent.  Relapses  are  always  associated  with  ulcerations  of 
the  tongue.  I  have  touched  these  ulcers  with  nitrate  of  silver,  not 
because  I  thought  it  a  good  thing,  but  because  I  did  not  know  what 
else  to  do.  Dr.  Barker's  discussion  of  pernicious  anemia  was  based 
on  general  lines  of  hygiene,  the  supply  of  hydrochloric  acid  and  of 
intestinal  antisepsis.  Dr.  Smithies  has  given  us  something  more 
tangible  to  work  upon.  It  may  be  added  that  in  certain  cases  treat- 
ment directed  against  infection  seems  to  have  done  some  good. 
Intravenous  injection  of  salvarsan,  which  perhaps  acts  as  an  anti- 
septic on  the  bacterial  side,  has  been  of  use,  I  have  seen  remarkable 
results  in  some  cases.  There  was  a  marked  reaction  and  rise  of 
temperature.  I  think  there  must  be  a  great  deal  of  truth  in  the 
theory  of  infection.  If  you  follow  treatment  along  this  line  you 
will  get  surprising  results. 

Dr.  Friedman  :  I  have  not  had  experience  with  acute  pernicious 
anemia,  but  I  have  observed  some  patients  for  from  eight  to  ten 
years.  Everyone  knows  that  in  pernicious  anemia  there  occur 
blood  crises,  especially  in  the  initial  stages.  On  one  examination 
you  will  find  a  typical  picture,  and  one  month  later  the  picture  is 
questionable,  for  instance  megaloblasts  will  not  be  found.  Improve- 
ments in  the  blood  picture  do  occur  even  without  treatment.  I 
don't  know  why  the  blood  picture  does  not  remain  constant.  It 
never  impressed  me  that  splenectomy  could  benefit  the  patient 
because  the  enlargement  of  the  spleen  is  certainly  a  secondary  con- 
dition in  pernicious  anemia.  In  hemolytic  jaundice,  which  is  due  to 
Hypersplenism,  this  really  is  of  service.  I  have  a  patient  who  is  well 
now  two  years  after  splenectomy  for  hemolytic  jaundice.  The 
two  conditions  are  different.  In  pernicious  anemia  enlargement  of 
the  spleen  is  not  so  pronounced  as  in  other  conditions.  The  spleen 
below  the  umbilicus  is  rare.  The  primary  condition  is  not  in  the 
spleen  or  in  the  bone  marrow.  As  to  the  infectious  nature  of  the 
disease,  I  think  Dr.  Smithies  has  produced  good  experimental  evi- 
dence in  his  cases.  We  are  accustomed  lately  to  attribute  all  latent 
infection  to  the  tonsils,  but  we  should  also  consider  gastric  ulcer, 
duodenal  ulcer,  appendicitis,  poliomyelitis.     We  shall  soon  be  look- 


96       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

ing  for  the  primary  site  of  all  these  infections,  which  used  to  be 
considered  the  tonsil.  If  these  cases  of  pernicious  anemia  can  be 
attributed  to  infection  the  discovery  is  of  great  importance  to  pre- 
ventive medicine.  In  regard  to  achylia  gastrica,  I  have  never  seen 
pernicious  anemia  without  this  symptom.  If  there  is  no  achylia, 
diagnosis  should  be  made  with  great  reserve.  Some  years  ago  I 
had  a  case  with  typical  picture  of  pernicious  anemia — with  normo- 
blasts, megaloblasts,  enlarged  spleen.  The  man  was  seen  also  at 
the  Roosevelt  hospital,  and  they  refused  to  make  a  diagnosis  of 
pernicious  anemia  there,  because  achylia  gastrica  was  not  present. 
It  seems  to  me  this  symptom  is  necessary  to  complete  the  diagnosis. 

Dr.  Baar:  If  I  had  had  nothing  else  to  repay  my  trip  here,  I 
should  have  been  abundantly  compensated  by  listening  to  this  paper, 
from  which  I  have  learned  very  much.  I  have  gotten  the  same  re- 
sults, but  in  addition  I  have  always  observed  a  constant  indicanuria, 
as  well  as  the  achylia  gastrica.  This  has  always  given  me  the  clue. 
If  I  don't  find  that,  the  case  falls  into  the  other  category  mentioned 
by  Dr.  Smithies.  In  one  case,  a  boy  of  nineteen,  with  enlarged  spleen 
and  liver  and  tender  gelatinous  swelling  of  the  glands  I  tried  sal- 
varsan  injections.  The  hemoglobin  improved  from  thirty  to  seventy- 
five  per  cent,  and  all  swellings  subsided  except  the  parotid 
swellings.  Later  the  patient  had  erysipelas  from  which  a 
streptococcus  was  recovered.  Then  he  had  a  focus  of  infec- 
tion in  the  sphenoid.  He  took  a  vaccine  treatment.  Then 
a  purulent  iritis  broke  out.  He  had  the  same  coccus  in  the  blood, 
the  parotid  and  the  naso-pharynx.  He  had  a  pronounced  indi- 
canuria. As  this  disappeared,  the  man's  hemoglobin's  came  up. 
In  another  case  of  supposed  pernicious  anemia,  in  a  woman,  I  found 
perforation  of  the  nasal  septum.  Salvarsan  cleared  up  the  condi- 
tion, which  was  congenital  syphilis.  The  immense  value  of  the 
"cocci"  statement  must  be  appreciated.  I  don't  think  it  is  a  case 
of  looking  for  bugs  in  the  tonsils.  They  are  there  undoubtedly  in 
many  cases.     Some  of  the  anemias  are  also  frequently  syphilitic. 

Dr.  W.  H.  Mercur:  I  am  interested  as  to  the  statement  by  Dr. 
Smithies  as  to  the  performance  of  fifty-one  laparotomies  in  this 
condition.  There  is  a  general  impression  that  splenectomy  is  the 
cure  for  this  condition.  Splenectomy  is  only  a  cure  when  the  spleen 
is  the  focus  of  infection;  in  other  words,  if  the  appendix  or  the 
gall  bladder  is  the  point  of  bacterial  infection,  taking  the  spleen 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      97 

out  won't  cure  the  disease.  I  remember  Dr.  Osier,  some  years  ago, 
in  a  case  of  pernicious  anemia,  said  "look  at  tbe  mouth;"  the  man 
had  decayed  teeth.  We  learned  to  look  for  trouble  with  the  teeth. 
In  regard  to  transfusion  in  these  cases,  one  point  advocated  by 
Percy  if  of  value.  One  may  take  all  precautions  to  prevent  hemo- 
lysis and  still  it  may  occur  and  cause  serious  trouble.  Percy  takes 
a  small  quantity,  one  half  c.c.  of  blood  and  introduces  that.  If  it 
causes  hemolysis  the  donor  is  unsuitable.  This  half  c.c.  will  cause 
trouble  in  ten  seconds,  if  at  all,  and  the  introduction  of  300  c.c.  of 
the  same  blood,  if  unsuitable,  would  cause  much  more  trouble. 
Personally  I  have  never  seen  cases  of  pernicious  anemia  get  well. 
Dr.  Smithies  says  he  had  twenty-six  cases  of  pernicious  anemia 
get  well  and  remain  so  from  six  to  fifty-one  months.  I  saw  the 
woman  he  refers  to  as  the  case  of  longest  duration.  She  certainly 
looked  robust  and  in  perfect  health.  It  may  be  that  if  the  source  of 
infection  is  removed  that  the  cure  is  permanent.  Dr.  Barach  spoke 
of  the  use  of  606-Arsenic  as  certainly  an  advantage  but  the  anemia 
in  those  cases  is  probably  syphilitic.  Bradley  of  Edinburgh  proved 
that  these  cases  in  which  salvarsan  was  beneficial  were  luetic  ane- 
mias. An  important  point  is  that  in  a  high  degree  of  anemia  the 
Wassermann  is  negative.  In  a  case  where  the  Wassermann  was 
negative,  autopsy  showed  lues  from  the  brain  down.  Much  per- 
nicious anemia  is  luetic  in  origin.  I  would  like  to  mention  one  case 
in  which  we  were  going  to  transfuse  a  pernicious  anemia  patient 
with  blood  from  his  brother.  The  patient  had  a  negative  Wasser- 
mann and  emphatically  denied  lues.  The  donor  showed  a  four 
plus  Wassermann.  When  he  was  questioned  he  said,  "Oh  yes,  I 
got  that  trouble  at  the  same  time  my  brother  did,"  which  shows 
that  the  Wassermann  reaction  is  negative  in  these  cases. 

Dr.  Friedman  :  I  would  like  to  ask  why  do  these  patients  have 
remissions  in  pernicious  anemia.  If  these  cases  originate  with 
infections,  do  they  have  reinfections?  One  point  made  I  don't 
think  was  well  taken.  It  was  stated  that  if  the  infected  tonsil  were 
removed  the  case  would  get  well.  This  does  not  necessarily  follow, 
because  the  damage  has  been  done,  but  that  does  not  prove  that  in- 
fection did  not  produce  the  disease. 

Dr.  Haythorn:  The  question  that  Dr.  Mercur  raised  about  the 
use  of  salvarsan  in  pernicious  anemia  should  be  considered.  Dr. 
Smithies  does  not  need  my  support,  that  is  evident,  but  I  would 


98       THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

say  that  in  the  last  three  autopsies  we  have  had,  we  have  recovered, 
either  from  the  bone  marrow,  hearts'  blood  or  spleen  a  virulent  pyo- 
genes and  an  unrecognized  spirillum.  Salvarsan  in  the  blood  stream 
is  a  bactericidal  agent  and  some  workers  have  cleared  up  streptococci 
in  the  blood  stream  by  this  means.  Experimental  animals  have  been 
saved  by  this  means.  I  don't  think  it  is  necessary  for  persons  to 
have  syphilis  to  be  benefited  by  salvarsan.  The  bone  marrow  must 
be  reached  by  the  injection.  I  would  like  to  see  salvarsan  used 
experimentally  in  cases  where  there  was  no  syphilis. 

Dr.  Ives  :  We  had  an  extremely  interesting  case  at  the  Mercy 
hospital  clinic  this  morning — an  endocarditis  due  to  streptococcus 
viridans  in  the  blood.  In  this  case  the  injection  of  salvarsan  cleared 
the  blood  stream  of  streptococci.  A  second  injection  for  the  same 
reason  raised  the  temperature,  which  came  down  in  the  course  of  a 
week.  The  third  injection  cleared  up  the  case,  which  ran  a  normal 
temperature  two  or  three  days  later.  This  would  seem  to  indicate 
that  the  temperature  was  caused  by  bacteria  in  the  blood,  which 
were  cleared  up  by  606.  It  would  seem  then  that  salvarsan  has 
bactericidal  action.  In  the  case  of  streptococcus  viridans  invasion 
of  the  tonsil,  disappearance  of  the  germs  can  be  caused  by  the  appli- 
cation of  arsenated  mercurio-inesol. 

Dr.  Frank  Smithies:  I  wish  to  thank  the  members  for  their 
interesting  discussion.  In  my  fragmentary  presentation,  many 
points  necessarily  were  left  uncovered.  In  this  disease  we  have 
definite  evidence  of  the  infective  process  in  the  mouth  as  in  pellagra, 
kala-azar,  sprue,  etc.  The  first  treatment  is  by  chlorate  of  potasli 
mouth  wash,  or  one-half  per  cent,  formalin  wash,  before  anything 
else  is  done.  Many  of  these  cases  are  non-lnetic  by  laboratory  tests 
and  it  is  concluded  that  the  action  of  salvarsan  is  bacteriolytic.  I 
am  glad  to  hear  reports  from  Dr.  Baar  of  intermittently  active  in- 
fections in  pernicious  poisoning.  The  type  is  a  low-grade  septicemia, 
by  protein  end-products  poisoning.  Salvarsan  reactions  upon  the 
temperature  and  anemia  and  one  could  class  this  disease  with  low 
grade  intermittent  infection,  much  as  kala-azar.  We  have  not  em- 
ployed salvarsan  in  every  case.  Two  had  had  salvarsan  before  they 
came  to  us.  Any  chronic  anemia,  such  as  anemia  in  cancer,  may 
be  called  pernicious.  The  anemia  is  a  lytic  anemia,  whether  it  is 
caused  by  bacterial  or  metabolic  products.  In  the  study  of  immense 
material,  Cabot  states  that  ninety-nine  per  cent,  have  died  within 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE      99 

three  and  one-half  years.  The  report  of  blood  tests  showed  that 
our  patients  had  had  all  the  remissions  they  were  going  to  have 
before  they  came  to  us.  Forty  per  cent,  were  brought  in  on  stretch- 
ers ;  some  in  extremis.  We  don't  know  about  spontaneous  cures, 
but  we  do  know  that  spontaneous  cures  have  not  been  hindered  by 
anything  that  we  have  done.  Recurrences  are  not  uncommon  after 
splenectomy.  The  hemo-lymph  nodes  in  the  spine  may  take  on  the 
function  of  destroying  the  red  blood  corpuscles.  Patients  may 
come  back  with  recurrence.  We  have  definite  alterations  in  the 
hemo-lymph  nodes  which  have  taken  up  the  functions  of  the  spleen. 
Dr.  Friedman  spoke  of  focal  infection.  It  is  not  sufficient  to  say 
infection  about  the  teeth  or  tonsils,  but  it  is  important  to  say  what 
type  of  infection.  Wre  may  have  vigorous  growth  of  harmless 
organisms  or  very  slow  growth  of  very  pathogenic  organisms. 
These  can  produce  serious  damage.  Removal  of  the  tonsil  does  not 
cure  this.  There  may  also  be  mutations  of  organism  which  are 
harmless  into  those  which  produce  serious  lesions.  Rosenow  has 
shown  this.  In  regard  to  achylia  gastrica — I  agree  that  this  is  a 
constant  finding  in  pernicious  anemia,  also  pancreatic  achylia.  This 
is,  however,  the  end  result,  where  the  damage  has  been  done.  We 
ought  now  to  study  the  living  pathology  instead  of  centering  our 
attention  on  dead-house  pathology.  If  the  surgeon  has  done  nothing 
else,  he  has  contributed  a  certain  amount  of  pathology  while  the 
patient  is  still  living.  Posterity  will  laugh  at  us  for  talking  of 
achylia  gastrica  and  gastric  atrophy.  It  is  a  symptom,  not  a  cause. 
Diminished  hydrochloric  acid  or  pancreatic  secretion  is  an  end  result. 
So  it  is  with  the  spleen.  It  has  suffered  from  a  chronic,  low  grade 
inflammatory  irritation,  and  there  is  no  intense  reaction  as  in  typhoid 
fever.  In  ten  of  these  spleens  we  may  not  find  any  organisms.  In 
the  next  ten  cases  there  may  be  organisms  in  the  tissues  of  every 
one.  The  bone  marrow  cultures  will  tell  us  what  organisms  we  are 
dealing  with  in  some  cases.  I  think  Dr.  Baar's  observations  about 
indicanuria  bring  out  the  point  of  the  chronic  intermittent  type  of 
infection  in  these  cases.  It  does  not  matter  whether  it  is  in  the 
gall  bladder,  the  alimentary  tract,  or  the  appendix,  so  long  as  it  is 
active,  it  will  produce  indicanuria.  I  wish  to  further  emphasize 
that  all  we  can  do  in  analyzing  these  cases  is  to  present  certain  facts 
and  let  men  interpret  them  for  themselves.  The  prophet  has  never 
been  very  successful,  as  far  as  history  goes.  The  point  I  wish  to 
leave  with  you  is  this,  in  the  treatment  of  pernicious  anemia,  we 
don't  treat  the  disease  by  splenectomy,  we  treat  it  on  the  basis  of 


100     THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

any  clinical,  pathological,  bacterial  focus.  That  teaches  us  to  re- 
duce any  infective  foci,  whether  external,  abdominal  or  elsewhere; 
and  to  counteract  infection  by  transfusion.  In  addition  treatment 
may  include  laparotomy  to  search  for  focal  infection,  and  to  remove 
the  spleen   if  the  organ   requires   removal. 

Dr.  R.  W.  Wilcox  :  It  may  seem  strange  that  we  have  had  to 
deal  with  so  many  instances  of  measles  and  mumps,  but  the  country 
boy  does  not  have  the  chance  to  acquire  immunity  against  these  dis- 
eases. The  gutter-snipe,  on  the  other  hand,  is  generally  immune  to 
any  and  every  infection.  The  measles  problem  is  not  difficult. 
Plenty  of  fresh  air  and  sunlight  soon  stop  the  epidemic.  Cerebro- 
spinal meningitis  patients  get  on  well  with  the  use  of  serum.  In 
regard  to  typhoid  and  paratyphoid  we  have  done  splendidly.  Some- 
times, however,  the  reaction  to  paratyphoid  inoculation  is  consid- 
erable. If  the  camp  water  supply  were  absolutely  safe,  there 
would  be  little  or  no  typhoid.  Dr.  Park  has  presented  extremly 
comprehensive  and  accurate  statements  in  a  very  interesting  paper. 

Dr.  R.  W.  Wilcox  :  I  desire  to  record  the  appreciation  and 
thanks  of  the  congress  for  the  hospitality  shown  by  Drs.  Jones, 
Lichty  and  Mercur  in  entertaining  us.  I  wish  this  statement  to  be 
incorporated  in  the  remarks  of  the  president  so  that  our  apprecia- 
tion of  the  efforts  of  the  local  committee  on  our  behalf  may  be 
duly  noted  in  the  Proceedings  of  the  Congress. 

The  American  Congress  on  Internal  Medicine  feels  a  loss,  irre- 
trievable, in  the  death  of  our  late  Secretary  General,  Dr.  Heinrich 
Stern.  For  a  year  or  more  prior  to  his  death,  Dr.  Stern  was 
seriously  ill  but  with  that  never- failing  perseverance  and  unselfish- 
ness which  he  manifested  all  through  his  life  he  forgot  his  own 
suffering  in  the  interest  of  our  organization.  Prior  to  the  meet- 
ings of  the  congress  in  1916  and  1917,  a  wonderful  supply  of  tem- 
porary energy  was  his,  which  enabled  him  to  be  in  attendance  in 
order  that  we  might  benefit  by  his  views,  that  he  might  guide  us 
with  his  unfailing  judgment.  Although  he  expressed  the  greatest 
pleasure  after  the  Pittsburgh  meeting,  the  trip  certainly  taxed  his 
strength,  and  this  together  with  the  extreme  cold  which  occurred 
at  that  time,  hastened  his  death  which  took  place  on  Jan.  30,  1918. 
Upon  unanimous  resolution  of  the  Council  of  the  Congress,  the 
following  Obituary  was  ordered  printed  in  the  Transactions  of  the 
year. 


THE  AMERICAN  CONGRESS  OX  INTERNAL  MEDICINE     101 


Jlemricf)  intern 

was  born  near  Frankfort,  Germany,  fifty  years  ago. 
Soon  after  arriving  in  this  country  he  began  the  study 
of  medicine.  He  received  his  first  Medical  Degree 
twenty- four  years  ago  and  a  few  years  later  he  took 
a  second  degree.  After  some  years  in  general  practice 
he  began  to  devote  himself  to  a  study  of  diseases  of 
metabolism.  The  prize  offered  by  the  New  York 
County  Medical  Society  for  the  best  essay  on  diabetes 
was  won  by  him  and  this  brought  him  to  the  notice  of 
the  profession.  From  that  time  on  his  work  was  con- 
sistently in  the  field  of  internal   medicine. 

He  was  connected  either  as  founder  or  member  of 
the  following  organizations :  The  Institute  for  Medi- 
cal Diagnosis,  Philantropen  Hospital,  Visiting  and 
later  Consulting  Physician,  St.  Mark's  Hospital.  Con- 
sulting Physician,  Central  Islip  and  Seney  Hospitals. 
Sometime  Professor  of  Clinical  Medicine  at  the  Ger- 
man West  Side  Post  Graduate  Medical  School.  Lec- 
turer on  Medicine,  Boston  University.  Founder  and 
Editor  of  the  Archives  of  Diagnosis.  Founder  of 
the  Manhattan  Medical  Society,  of  the  American 
Congress  on  Internal  Medicine,  and  of  the  American 
College  of  Physicians,  which  was  the  fulfilment  of  a 
life-long  dream. 

In  addition  he  was  a  member  of  many  other  medi- 
cal societies.  He  was  the  author  of  upward  three 
hundred   medical   articles   and   of   a   half-dozen   text- 


102     THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 


books   on  medicine,  most  of   which   were  devoted   to 
treatment  of  disease  in  its  various  phases. 

About  fifteen  years  ago,  Dr.  Stern  conceived  the 
idea  of  a  congress  of  internists,  that  should  not  be 
limited  to  those  in  prominent  teaching  positions  but 
that  should  be  open  to  all  of  the  profession  who  were 
particularly  interested  in  internal  medicine — and 
among  those,  who  by  meritorious  work,  study  and 
investigation  had  done  something  for  the  good  of 
humanity  and  the  profession,  a  certificate,  causa  hon- 
oris, in  the  American  College  of  Physicians,  should 
be  given.  These  dreams  and  ideals  he  repeated 
time  and  again  to  his  friends  until  finally  he 
interested  some  of  his  professional  brethren  who  saw 
the  truth  and  possibilities  of  his  concept.  After  much 
labor  and  deliberation,  stimulated  and  abetted  by  his 
enthusiasm,  the  American  Congress  on  Internal  Medi- 
cine and  its  exemplar — The  American  College  of 
Physicians — were  formed.  When  these  were  fully 
organized  and  had  justified  his  prophecy,  it  was  denied 
him,  as  it  was  to  Moses  of  olden  time,  that  he  should 
see  the  promised  land  in  the  progress  and  brilliant 
success  of  these  organizations  which  will  be  perma- 
nent memorials  of  their  founder  and  the  ideals  of 
the  internists  and  consultant  which  have  become 
actualities. 

Reynold  Webb  Wilcox,  Chairman. 
Thomas  F.  Reilly. 
Joseph  H.  Byrne. 


CONSTITUTION 


ARTICLE    I 


This  organization  shall  be  known  as  The  American  Congress  on 
Internal    Medicine. 

ARTICLE    II 

The  objects  of  the  congress  shall  be:  To  promote  the  advance- 
ment of  the  science  and  practice  of  medicine,  to  further  the  study 
of  biological  medicine  among  its  members,  to  elevate  the  standard  of 
preliminary  education  of  physicians  and  the  standing  of  medical 
education,  and  to  secure  enactment  of  just  medical  laws  by  the  State 
and  Federal  Governments  and  of  a  Federal  Law  providing  for  a 
national  medical  license,  to  obtain  the  establishment  of  a  National 
Board  of  Health,  to  promote  friendly  intercourse  among  physicians, 
to  enlighten  and  direct  public  opinion  in  regard  to  the  great  prob- 
lems of  health  and  medicine,  and  to  unite  those  working  in  the 
domain  of  internal  medicine,  to  secure  recognition  for  the  term 
internist  as  the  proper  designation  for  such  workers  and  to  obtain 
proper  scientific  and  material   recognition  of  their  work. 

ARTICLE  III 

The  congress  shall  meet  annually  at  such  time  and  place  as  the 
council  may  determine.  Twenty-five  members  shall  constitute  a 
quorum. 

ARTICLE    IV 

Section  i.  The  officers  of  the  congress  shall  consist  of  a  presi- 
dent, a  vice-president,  a  secretary-general,  a  treasurer,  and  twenty- 
five  councilors,  who  with  the  officers  shall  constitute  the  council, 
all  to  be  elected  from  the  active  membership  by  ballot  at  an  annual 
meeting,  a  majority  of  whom  shall  reside  in  the  city  of  New  York 
or  its  vicinity,  excepting  that  the  secretary-general  shall  be  elected 
for  a  term  of  ten  years. 

103 


104     THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 

Sec.  2.  The  council  may  be  convened  at  any  time  by  the  presi- 
dent at  the  request  of  any  five  of  its  members.  Its  decisions  shall 
be  equivalent  to  acts  of  the  congress,  and  shall  be  reported  to  it  at 
its  next  regular  meeting.  The  council  shall  constitute  the  nom- 
inating committe  of  the  congress. 

Sec.  3.  A  vacancy  occurring  in  any  office  may  be  filled  by  the 
council. 

ARTICLE  V 

Section  i.  Any  qualified  physician  engaged  in  the  general  or 
special  practice  of  internal  medicine  or  in  laboratory  research  per- 
taining to  it,  may  be  proposed  for  fellowship. 

Sec.  2.  Applications  for  fellowship  in  the  congress  should  be 
made  in  writing  to  the  council.  Five  negative  ballots  shall  reject  an 
applicant. 

Sec.  3.  Applications  for  fellowship  shall  be  accompanied  by  the 
annual  dues  of  five  dollars. 

Sec.  4.  Resignation  of  fellows  shall  not  be  accepted  until  all 
dues  have  been  paid. 

article  VI 

All  proposed  changes  in  the  constitution  must  be  offered  in  writing 
at  a  regular  meeting  of  the  congress.  They  are  to  be  considered 
only  at  the  next  annual  meeting  when  a  two-thirds  vote  of  the  mem- 
bers present  shall  be  necessary  for  their  adoption. 


BY-LAWS 


ARTICLE    I 


The  President  shall  preside  at  the  annual  meeting  of  the  Con- 
gress and  deliver  an  address,  and  shall  be  the  chairman  of  the 
Council.  In  the  absence  of  the  President,  the  Vice-President  shall 
preside. 

ARTICLE   II 

The  secretary-general  shall  keep  a  record  of  the  transactions  of 
the  congress,  and  the  council,  and  committees,  conduct  all  corre- 


THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE     105 

spondence  of  the  congress,  and  mail  to  each  fellow  a  program  of 
the  meeting  at  least  two  weeks  in  advance  of  the  date  thereof. 
The  records,  publications  and  seal  of  the  congress  shall  be  in  his 
custody. 

ARTICLE   III 

The  treasurer  shall  collect  all  moneys  due  the  congress,  disburse 
the  same  as  directed  by  the  council,  keep  a  proper  account  of  all  his 
transactions,  and  render  an  annual  statement  to  the  congress.  He 
shall  have  charge  of  all  property  belonging  to  the  congress  not 
otherwise  provided  for.  He  shall  give  bonds  for  the  faithful  per- 
formance of  his  duty,  in  such  sum  as  shall  be  determined  by  the 
council. 

ARTICLE  IV 

The  council  shall  constitute  a  standing  committee  to  consider  all 
matters  of  interest  to  the  congress.  It  shall  appoint  all  committees 
and  conduct  all  business  affairs  of  the  congress.  It  may,  in  its 
discretion,  organize  special  scientific  and  local  sections  of  the 
congress. 

Five  members  of  the  council  shall  be  elected  annually  by  the  con- 
gress, each  to  serve  for  a  term  of  five  years. 

article  v 

Charges  against  any  fellow  must  be  made  in  writing.  They 
shall  be  referred  to  the  council  for  investigation  and  action. 

ARTICLE   VI 

The  annual  dues  shall  be  five  dollars,  payable  before  the  annual 
meeting. 

ARTICLE  VII 

The  order  of  business  shall  be  as  follows: 

(1)  Reading  of  the  minutes  of  preceding  meeting. 

(2)  Reports  of  officers,  of  the  council  and  committees. 

(3)  Presentation  of  communications. 

(4)  Miscellaneous  business. 

(5)  Election  of  officers  for  the  ensuing  year. 


FELLOWS  OF  THE  AMERICAN  CONGRESS  ON 
INTERNAL  MEDICINE,  1917-1918. 


Aaron,  Charles  O.,  Detroit,  Mich. 
Acuff,  S.  D.,  Knoxville,  Tenn. 
Alexander,  J.  Hope,  Pittsburgh,  Pa. 
Also]),  Thos.,  Atlantic  City,  N.  J. 
Amster,  J.  Lewis,  New  York  City. 
Altshul,  H.,  Hartford,  Conn. 
Anders,  James  M.,  Philadelphia,  Pa. 
Arneill,  James  Rae,  Denver,  Colo. 
Aten,  William  H.,  Brooklyn,  N.  Y. 

Baar,  Gustav,   Portland,  Ore. 
Babcock,  Robert  H.,  Chicago,  111. 
Bacon,  Theo.  T.,  Springfield,  Mass. 
Baketel,  H.  S.,  New  York  City. 
Bangs,  Charles  H.,  Boston,  Mass. 
Barach,  Jos.  H.,  Pittsburgh,  Pa. 
Barnes,  James,  Cicero,  111. 
Barnes,  Noble  P.,  Washington,  D.  C. 
Bartley,  E.   H.,   Brooklyn,   N.   Y. 
Bate,  R.  Alex.,  Louisville,  Ky. 
Bathurst,  Wm.  R.,  Ark. 
Beck.  Harvey  G.,  Baltimore,  Md. 
Beling,  C.  C,  Newark,  N.  J. 
Bell,  Tohn  M.,  St.  Joseph,  Mo. 
Benedict,  A.  L.,  Buffalo,  N.  Y. 
Berg,  G    F.,  Pittsburgh,  Pa. 
Berger,  Samuel  S.,  Cleveland,  O. 
Bettman,  Henry  W.,  Cincinnati,  O. 
Betts,  Lester,  Schenectady,  N.  Y. 
Biddle.  Andrew  P.,  Detroit,  Mich. 
Bieber,  Joseph,  New  York  City. 
Billings.  Fredk.  T.,  Pittsburgh,  Pa. 
Bishop,  Ernest  S.,  New  York  City. 
Bishop,  James,  New  York  City. 
Bishop,  L.  F.,  New  York  City,  N.  Y. 
Blackwood,  A.  L.,  Chicago,  111. 
Bloch,  Leon,  Chicago,  111. 
Blackwood,  A.  L.,  Chicago,  111. 
Bohan,  P.  T.,  Kansas  City,  Mo. 
Bonney,  Sherman  G.,  Denver,  Colo. 
Bosworth,  Robinson,  St.  Paul,  Minn. 
Bowen,  William,  Knoxville,  Tenn. 
Briggs,  L.  Vernon,  Boston,  Mass. 
Brockway,  Robt.  O.,  Brooklyn,  N.  Y. 
Brooks,  Harlow,  New  York  City. 
Brown,  Alex.  G.,  Richmond,  Va. 
Brown,  Samuel  S.,  Brooklyn,  N.  Y. 
Buesser,  Fredk.  G.,  Detroit,  Mich. 


Bumsted,  C.  R.,  Newark,  N.  J. 
Bunker,  Henry  A.,  Brooklyn,  N.  H. 
Burns,  G.  H.,  Central  Islip,  X.  Y. 
Burrage.  Thomas  J.,  Portland,  Me. 
Butler,  Glent.  R.,  Brooklyn.  N.  Y. 
Byrne,  Joseph,  New  York  City. 
Byrne,  Jos.  Henry,  New  York  City. 

Caille,  August,  New  York  City,  N.  Y. 
Calvert,  W.  J.,  Dallas,  Tex. 
Carman,  Albro  R.,  New  York  City. 
Cassidy,  John  M.,  Jersey  City,  N.  J. 
Chapin,  Edward,  Brooklyn,  N.  Y. 
Christie.  Arthur  C,  Corry,  Pa. 
Churchill,  Jas.  F..  San  Diego,  Cal. 
Clark,  Ramond,  Brooklyn,  N.  Y. 
Cohen,  Bernard.  Buffalo,  N.  Y. 
Collins,  Danl.  W.,  Wilkes-Barre,  Pa. 
Conklin,  C.  B.,  Washington,  D.  C. 
Connolly,  Richard  N.,  Newark,  N.  J. 
Connor,  Guy  L.,  Detroit,  Mich. 
Conway,  F.  C.  Albany,  X.  Y. 
Cooper,  W.  G.,  Ogdensburg,  N.  Y. 
Corbus,  B.  R.,  Grand  Rapids,  Mich. 
Cornwall,  E.  E.,  Brooklyn,  N.  Y. 
Coughlin,  Robert  E.,  Brooklyn,  N.  Y. 
Coulter,  F.  E.,  Omaha,  Neb. 
Crafts,  Leo  M.,  Minneapolis,  Minn. 
Cramp,  Arthur  J.,  Chicago,  111. 
Crofton,  Alfred  C,  Chicago,  111. 
Cruikshank,  Wm.  J.,  Brooklyn.  N.  Y. 
Cullings,  Jesse  J..  Memphis,  Tenn. 
Cummings,  Rol.,  Los  Angeles,  Cal. 
Curtis,  Grant  P.,  Union,  N.  J. 
Cutler.  William  W.,  Peoria.  111. 

Daland,  Judson,  Philadelphia,   Pa. 
Dattelbaum,  M.  J.,  Brooklyn,  N.  Y. 
De  Buys,  L.  R..  New  Orleans,  La. 
De  Lorme,  M.  F.,  Brooklyn,  N.  Y. 
Dercum,   Francis   X.,   Phila.,   Pa. 
De  Yoanna.  A.,  Brooklyn,  XT.  Y. 
Dickinson,  H.  S.,  Philadelphia,  Pa. 
Dill,  George  H  .  Utica,  X.  Y. 
Diner,  Jacob.  Xew  York  City.  X.  Y. 
Dobkin,  XTicholas,  Brooklyn,  X.  Y. 
Donald,  Wm.  M.,  East  Detroit,  Mich. 
Donovan,  Daniel  J.,  Xew  York  City. 


107 


108     THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 


Dowd,  Ambrose  F.,  Newark,  N.  J. 
Dowden,  C.  W.,  Louisville,  Ky. 
Dunklin,  F.  B.,  Nashville,  Tenn. 
Dunn,  A.  D.,  Omaha,  Neb. 

Eckel,  John  L..  Buffalo,  N.  Y. 
Edson,  David  Orr,  New  York  City. 
Egan,  Cornelius  J.,  New  York  City. 
Eichler,  Philip,  Bronx,  New  York. 
Elliott,  Daniel,  Newark,  N.  J. 
Evans,  Britton  D.,  Greystone,  N.  J. 
Evans,  George  A.,  Brooklyn,  N.  Y. 
Evans,  Wm.  A.,  Detroit,  Mich. 

Fairbairn,  Henry  A.,  Brooklyn,  N.  Y. 
Fassett,  Chas.  W.,  Kansas  City,  Mo. 
Faust,  Louis,  Schenectady,  N.  Y. 
Field,  C.  Everett,  New  York  City. 
Finck,  T.  D.,  Louisville,  Ky. 
Fishbaugh,  E.  C,  Los  Angeles,  Cal. 
Fisher,  Charles  M.,  Brooklyn,  N.  Y. 
Fisher,  Ernest  M., Greystone  Park,N.J. 
Flagg,  Fredk.  W.,  Rockaway,  N.  J. 
Fleischaker,  F.  W„  Louisville,  Ky. 
Fliedner,  G.  B.,  Cleveland,  O. 
Fontaine,  Bryce  W.,  Alemphis,  Tenn. 
Friedman,  G.  A.,  New  York  City. 
Friend,  John  M.,  Cleveland,  O. 
Fuller,  Frank  M.,  Keokuk,  la. 
Futterer,  Gus.  A.,  Chicago,  111. 

Gehring,  E.  W.,  Portland,  Me. 
George,  S.,  Pittsburgh,  Pa. 
Gerin,  John,  Auburn,  N.  Y. 
Gibson,  Arthur  R.,  Buffalo,  N.  Y. 
Goddard,  W.  W.,  Schenectady,  N.  Y. 
Gompertz,  L.  M.,  New  Haven,  Conn. 
Gordon,  Alfred,  Philadelphia,  Pa. 
Gordon,  Murray  B.,  Brooklyn,  N.  Y. 
Gottlieb,  Charles,  New  York  City. 
Gould,  L.  A.,  Schenectady,  N.  Y. 
Grandy,  Charles  R.,  Norfolk,  Va. 
Granger,  Frank  B.,  Boston,  Mass. 
Graves,  M.  L.,  Galveston,  Tex. 
Gray,  T.  N.,  East  Orange,  N.  J. 
Graves,  Nathaniel  A.,  Chicago,  111. 
Grayson,  Cary  T.,  Washington,  D.  C. 
Grayson,  Thos.  W.,  Pittsburgh,  Pa. 
Greeff,  L  G.  Wm,  New  York  City. 
Greene,  Chas.  L.,  St.  Paul,  Minn. 
Greiwe,  John  E.,  Cincinnati,  O. 
Griswold,  Alex.  V.,  Louisville,  Ky. 
Gutman,  J.,   Brooklyn,  N.  Y., 

Haass,  E.  W.,  Detroit,  Mich. 
Hall,  Josiah  N.,  Denver,  Colo. 


Halpern,  J.,  New  York  City,  N.  Y. 
Ham,  Still.  S.,  Schenectady,  N.  Y. 
Hamilton,  H.  D.,  Kansas  City,  Mo. 
Hangarter,  And.  H.,  Brooklyn,  N.  Y. 
Harrison,  Bev.  Drake,  Detroit,  Mich. 
Hatch,  J.  Leffmg'll,  New  York  City. 
Head,  Geo.  D.,  Minneapolis,  Minn. 
Heller,  Jos.  AL,  Washington,  D.  C. 
Hemmeter,  John  C,  Baltimore,  Md. 
Henderson,  Max.,  Louisville,  Ky. 
Henschel,  L.  K.,  Greystone  Pk.,  N.  J. 
Heussy,  Wm.  C.,  Seattle,  Wash. 
Hiatt,  Houston  B.,  High  Point,  N.  C. 
Hickey,  Preston  AL,  Detroit,  Mich. 
Hill,  Eben  C,  Poughkeepsie,  N.  Y. 
Hodges,  Fred  M.,  Rihcmond,  Va. 
Hodges,  J.  Allison,  Richmond,  Va. 
Hoff,  Peder  A.,  St.  Paul,  Minn. 
Hollis.  A.  Wm.,  New  York  City. 
Hollister,  Frank  C,  New  York  City. 
Holmes,  Arthur,  Detroit,  Mich. 
Horine,  Emmet  F.,  Louisville,  Ky. 
Horowitz,  Philip,  New  York  City. 
Hoxie,  George  H.,  Kansas  City,  Mo. 
Hoxsie,  Edward  H.,  Brooklyn,  N.  Y. 
Hubbard,  W.  S.,  Brooklyn,  N.  Y. 
Hunt,  Edward  L.,  New  York  City. 
Hunter,  George  G.,  Los  Angeles,  Cal. 

Inglis,  David,  Detroit,  Mich. 
Ives,  Augustus  W.,  Detroit,  Mich. 
Ives,  Robert  F.,  Brooklyn,  N.  Y. 

Jackson,  Edw.  W.,  Rochester,  N.  Y. 
Jager,  Thor.,  Wichita,  Kan. 
Jelly,  Arthur  C,  Boston,  Mass. 
Jenkins,  Wm.  A.,  Louisville,  Ky. 
Jennings,  C.  G.,  Detroit,  Mich. 
Johnson,  George  C,  Pittsburgh,  Pa. 
Johnston,    J.    I.,    Pittsburgh,    Pa. 
Jonah,  Wm.  E.,  Atlantic  City,  N.  J. 
Jones,  Allen  A.,  Buffalo,  N.  Y. 
Jones,  Clement  R..   Pittsburgh,  Pa. 
Jones,  Frank  A.,  Alemphis,  Tenn. 
Jutte,  Alax  Ernest,  New  York  City. 

Katzenbach,  W.  H..  New  York  City. 
Kaufman,  Albert,  Wilkes-Barre,   Pa. 
Kaufman,  F.  J.,  Syracuse,  N.  Y. 
Kaufman,  Jacob,  New  York  City. 
Kauffman,  Lesser,  Buffalo,  N.  Y. 
Kelly,  Thomas,   New  York  City. 
Kerr,  Le  Grand,  Brooklyn,  N.  Y. 
Keyes,  F.  P.,  Brooklyn,  N.  Y. 
Kiefer,  Guy  L.,  Detroit,  Mich. 


THE  AMERICAN  CONGRESS  ON  I  XT  URN. II.  MEDICINE     109 


Kimmel,  M.  S.,  Republic,  Pa. 
King,  George  W.,  Secaucus,  N.  J. 
Riser,  Edgar  F.,  Indianapolis,  Ind. 
Klein,  Abraham,  Brooklyn,  N.  V. 
Rrafft,  Jacob  C,  Chicago,  111. 

Lane,  Wilfred  H.,  Brattleborough,  Vt. 
Lape,  George  S.,  Binghamton,  N.  Y. 
Laporte,  Geo.  L.,  New  York  City. 
Lappeus,  J.  C.  S.,  Binghamton,  N.  Y. 
Lath,  Eugene  M.,  Rochester,  N.  Y. 
Lee,  John,  Detroit,  Mich. 
Lee,  Thomas  S.,  Washington,  D.  C. 
Levy,  I.  Harris,  Syracuse,  N.  Y. 
Levy,  I.  J.,  New  York  City,  N.  Y. 
Levy,  Louis  H.,  New  Haven,  Conn. 
Le  Wald,  Leon  T.,  New  York  City. 
Lewi,  Emily,  New  York  City,  N.  Y. 
Lewis,  H.  Edwin,  New  York  City. 
Lichty,  John  A.,  Pittsburgh,  Pa. 
Litchfield,  Lawrence,  Pittsburgh,  Pa. 
Little,  George  F.,  Brooklyn,  N.  Y. 
Loewenburg,  Saml.  A.,  Phila.,  Pa. 
Louria.   Leon,   Brooklyn,   N.   Y. 
Love,  F.  W.,  Buffalo,  N.  Y. 
Love,  Win.  S.,  Baltimore,  Aid. 
Loveland,  B.  C,  Syracuse,  N.  Y. 
Lowrey.  James  H.,  Newark,  N.  J. 
Lucas,  C.  G.,  Louisville,  Ky. 
Ludlum,  W   D.,  Brooklyn,  N.  Y. 
Lynch,  John  C,  Bridgeport,  Conn. 
Lytle,  Albert  T.,  Buffalo,  N.  Y. 

Magruder,  W.  Edw.,  Baltimore,  Md. 
Maier,  Otto,  New  York  City,  N.  Y. 
Mallory,  Wm.  J.,  Washington,   D.  C. 
Mannheimer,  George,  New  York  City. 
Martland,  Harrison  S.,  Newark,  N.  J. 
Matson,  Ralph  C,   Portland,  Ore. 
Mayer,  Edw.  E.,  Pittsburgh,  Pa. 
Mayhew,  John  Mills,  Lincoln,  Neb. 
Melirig,  Nelson  C,  Chicago,  111. 
Meltzer,  Victor,  New  York  City. 
Mercur,  Wm.  H.,  Pittsburgh,  Pa. 
Meuer,  S.  H.,  New  York  City,  N.  Y. 
Meyers,  Sidney  J.,  Louisville,  Ky. 
Monae-Lesser,  Mozart,  N.  Y.  City. 
Mooney,  Louis  M.,  New  York  City. 
Moore,  Ross,  Los  Angeles,  Cal. 
Moren,  John  J.,  Louisville,  Ky. 
Morgan,  Tas.  D.,  Washington,  D.  C. 
Morgan,  Wm.  G.,  Washington,  D.  C. 
Morrison,  A.  W.,  Minneapolis,  Minn. 
Moses,  Henry  M.,  Brooklyn,  N.  Y. 
Mulligan,  Wes.  T.,  Rochester,  N.  Y. 


Mulhearn,  W.  A.,  Augusta,  Ga. 

McBlaine,  T.  J.,  Niagara  Falls,  N.  Y. 
McCaskey,  Geo    W..  Ft.  Wayne.  Ind. 
McCaughey,  Robt.  S.,  Mason  City,  la. 
McClanahan,  H.  M.,  Omaha,  Neb. 
McCreedy,  E.  B.,  Pittsburgh,  Pa. 
McCrudden,  Francis  H.,  Boston,  Mass. 
MacEvitt,  James  M.,  Brooklyn,  N.  Y. 
McGraw,  T.  A.,  Jr.,  Detroit,  Mich. 
McGruder,  W.  Edw.,  Baltimore,  Md. 
McKclvey,  James  P.,  Pittsburgh,  Pa. 
McPherson,  O.  P.,  Kansas  City,  Mo. 
McSweeny,  E.  S.,  New  York  City 

Nash,   Philip  I.,  Brooklyn,  N.  Y. 
Nilson,  C.  Stuart,  Tacoma,  Wash. 
Nisbit,  W.  C,  Charlotte,  N.  C. 
Norbury,  Frank  P.,  Springfield,  111. 
Norden,  H.  A.,  Chicago,  111. 
Northridge,  W.  A.,  Brooklyn,  N.  Y. 

O'Hail,  Joseph  C,  Pittsburgh,  Pa. 
O'Mara,  John  T.,  Baltimore,  Md. 
Orbison,  Thos  J.,  Los  Angeles,  Cal. 
Overton.  W.  T.,  Binghamton,  N.  Y. 

Palmer,  G.  A.,  Pittsburgh,  Pa. 
Pease,  Marshall  C,  New  York  City. 
Peers,  Robert  A.,  Colfax,  Col. 
Pettit,  Albert,   Pittsburgh,   Pa. 
Pfeiffer,  Felix,  New  York  City. 
Philips,  Carlin,  New  York  City. 
Pollak,  B.  S.,  Secaucus,  N.  J. 
Polozker,  I.  L.,  Detroit,  Mich. 
Pottenger,  F.  M.,  Monrovia,  Cal. 
Pryor,  John  H.,  Buffalo,  N.  Y. 
Pumpyea,  P.  C,  New  York  City. 
Putnam,  James  W.,  Buffalo,  N.'Y. 

Quackenbos.  H.  F.,  New  York  City. 
Quintard,   Edward,   New  York   City. 

Ramirez,    Max   A.,   New   York   City. 
Reed,  Edw.  H.,  Washington,  D.  C. 
Reed,  Fred  C,  Schenectadv,  N.  Y. 
Reed,  Ralph  G.,  Central  Islip,  N.  Y. 
Reeves,   Rufus   S.,    Philadelphia,    Pa. 
Reifenstein,  E.  C,  Syracuse,  N.  Y. 
Reilly,  T.  F.,  New  York  City,  N.  Y. 
Rice,  James  F.,  Buffalo.  N.  Y. 
Richardson,  E.   T.,  New  York  City. 
Robinson,   D.,   New   York   City. 
Rochester,  Delancey,  Buffalo,  N.  Y. 
Roebuck,  L.  L.,  Richwood,  O. 
Rooney,  James  F.,  Albany,  N.  Y. 
Rothenberg,  L.  H.,  New  York  City. 


110     THE  AMERICAN  CONGRESS  ON  INTERNAL  MEDICINE 


Rottenberg,  I.  M.,  New  York  City. 
Roussel,  Albert  E.,  Philadelphia,  Pa. 
Roy,  Philip  S.,  Washington,  D.  C. 
Ryan,  Granville  W.,  Des  Moines,  la. 

Sachs,  Adolph,  Omaha,  Neb. 
Sachs,  L.  B.,  New  York  City,  N.  Y. 
Sajous,  Chas.  E.  de  M.,  Phila.,  Pa. 
Salzman,   Samuel,  Toledo,  O. 
Sargeant,  L.  D.,  Washington,  Pa. 
Satterthwaite,  T.  E.,  New  York  City. 
Schapira,  S.  Wm.,  New  York  City. 
Schlapp,  Max  G.,  New  York  City. 
Schweikhart,  Fred.  J.,  Elmhurst,  N.  Y. 
Scott,  George  D.,  New  York  City. 
Scott,  J.  M.  W.,  Schenectady,  N.  Y. 
Seufert,  E.  C,  Chicago,  111. 
Shearer,  Thos.  L.,  Baltimore,  Md. 
Sheldon,  Wm.  H.,  New  York  City. 
Sherman,  G.  H.,  Detroit,  Mich. 
Sherrill,  A.  W.,  Pittsburgh,  Pa. 
Sillo,  Valdemar,  New  York  City. 
Simonton,  F.  A.,  Pittsburgh,  Pa. 
Slaymaker,  Samuel  R.,  Chicago,  111. 
Smith,  A    D.,  Brooklyn,  N.  Y. 
Smith,  Ernest  B.,  Philadelphia,  Pa. 
Smith,  John  Hall,  Boston,  Mass. 
Smith,  Joseph  E.,  Broooklyn,  N.  Y. 
Smithies,  Frank,  Chicago,  111. 
Soiland,  Albert,  Los  Angeles,  Cal. 
Somers,  J.  A.,  Brooklyn,  N.  Y. 
Stapleton,  Wm.  J.,  Detroit,  Mich. 
Stark,  M..  New  York  City,  N.  Y. 
Stearns,  Wm.  G.,  Chicago,  111. 
Steiner,  Edwin,  Newark,  N.  J. 
Stella,  Antonio,  New  York  City. 
Stewart,  C.  E.,  Battle  Creek,  Mich. 
Stewart,  F.  E.,  Philadelphia,  Pa. 
Stewart,  W.  B.,  Atlantic  City,  N.  J. 
Stewart,  W.  H.,  New  York  City. 
Stillman,  Edgar  R.,  Troy,  N.  Y. 
Stith,  Robert  M.,  Seattle,  Wash. 
Stone,  Warren  B.,  Schenectady,  N.  Y. 
Stoner,  Willard  C,  Cleveland,  O. 
Strietmann.  Wm.  H.,  Oakland,  Cal. 
Strodl,  George  T.,  New  York  City. 
Swan,  John  M.,  Rochester,  N.  Y. 
Swink,  Walter  T.,  Memphis,  Tenn. 

Teeter,  Charles  E..  Newark,  N.  J. 
Thorns,  Fridolin,  Buffalo,  N.  Y. 
Thorne,  F,  H.,  Greystone  Pk.,  N.  J. 
Thorne,  T.  M.,  Pittsburgh,  Pa. 
Tice,  Frederick,  Chicago,  111. 


Tichenor,  G.  H.,  Jr.,  New  Orleans. 
Titus,  Edward  C,  New  York  City. 
Trapp,  Albert  R.,  Springfield,   111. 
Tuley,  Henry  Enos,  Louisville,  Ky. 
Tuohy,  E.  L.,  Duluth,  Minn. 
Turck,  Fenton  B.,  New  York  City. 

Ullman,  Julius,  Buffalo,  N.  Y. 
Updegraff,  R.   K.,  Cleveland,  Ohio 
Utley,  Frederick  H.,  Pittsburgh,  Pa. 

Van  Cott,  J.  M.,  Brooklyn,  N.  Y. 
Vander,  Bogart  F.,  Schenectady,  N.  Y. 
Vander  Hoof,  D.,  Richmond,  Va. 
Van  Wart,  R.  M.,  New  Orleans,  La. 
Vaux,  Chas.  L.,  Central  Islip,  N.  Y. 
Verbrycke,  J.  R.,  Washington,  D.  C. 
Visscher,  Louis  G.,  Los  Angeles,  Cal. 
Von  Ruck,  Silvio,  Asheville,  N.  C. 
Von  Tiling,  J.  H.  M.  A., 

Poughkeepsie,  N.  Y. 
Voorsanger,  Wm.  C,  San  Fran.,  Cal. 

Wachsmann,  S.,  New  York  City. 
Walsh.  Thomas  J.,  Buffalo,  N.  Y. 
Warfield,  Louis  M.,  Milwaukee,  Wis. 
Warmuth,  M.  P.,  Philadelphia,  Pa. 
Warren,  L.  F.,  Brooklyn,  N.  Y. 
Watkins,  John  T.,  Detroit,  Mich. 
Weber,  Leonard  G.,  New  York  City. 
Webster,  Henry  G.,  Brooklyn,  N.  Y. 
Weinstein,  J.  W.,  New  York  City. 
Weiss,  Samuel,  New  York  City,  N.  Y. 
Welker,  Franklin,  New  York  City. 
Wendel,  Henry  C,  Cincinnati,  O. 
Wessels,  W.  F.,  Los  Angeles,  Cal. 
Westervelt,  H.  C.  Pittsburgh,  Pa. 
Wheeler,  Robert  T.,  Brooklyn,  N.  Y. 
Whelan.  Edward  P.,  Nutley,  N.  J. 
Wilcox,  R.  W.,  New  York  City. 
Williams,  J.  R.,  Rochester,  N.  Y. 
Wilson,  C.  S.,  Tacoma,  Wash. 
Wilson,  Walter  J.,  Detroit,  Mich. 
Winter,  Henry  Lyle,  Cornwall,  N.  Y. 
Wiseman,  Tos.  R.,  Syracuse,  N.  Y. 
Witherspoon,  J.  A.,  Nashville,  Tenn. 
Witter,  Orin  R.,  Hartford.  Conn. 
Wolf,  I.  J.,  Kansas  City,  Mo. 

Youngling,  Geo.  S.,  New  York  City. 

Zbinden,  Theodore,  Toledo,  O. 
Zueblin.  Ernest,  Baltimore.  Md. 
Zugsmith,  Edwin,  Pittsburgh,  Pa. 


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